Student Registration Form

Sisu of Georgia, Inc. Registration Form
Child's Info
For which school year are you registering for?
Image of Child
Child's Name *

First NameLast Name
Date of Birth *

MonthDayYear
Date
Sex*

FemaleMale
Child's Home Language*

EnglishSpanishOther
County of Residence *
Child's Primary Address *

Street Address

Street Address Line 2

CityState

Zip Code
Legal Custody*

Both Parents [married]Legal Joint Custody [separated/divorced]Mother OnlyFather OnlyOther
Child Lives With*

Both ParentsMother OnlyFather OnlyOther
Sisu must have offical documentation on file if there are specific custody arrangements, restricted pick-ups or other issues related to student drop-off and pick-up.

Individuals living in the home other than Parent/Guardian (enter none in first box if no other family in the home)*

Rows	Name	Age	Relationship to Child
Person 1
Person 2
Person 3
Person 4

Parent/Guardian 1
Parent Name *

First NameLast Name
Relation to child*

MotherFatherGrandmotherGrandfatherAuntUncleFoster ParentOther
Address [if different than child]

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer *
Occupation *
Work Phone
Format: (000) 000-0000.
Work Address (type N/A in first box if unemployed)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone *
Format: (000) 000-0000.
Email *
example@example.com
Preferred Contact Method*

WorkCellEmail
Parent/Guardian 2
Parent Name

First NameLast Name
Relation to child

MotherFatherGrandmotherGrandfatherAuntUncleFoster ParentOther
Address [if different than child]

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer
Occupation
Work Phone
Format: (000) 000-0000.
Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Format: (000) 000-0000.
Email
example@example.com
Preferred Contact Method

WorkCellEmail
Emergency Contacts & Authorized Pick-Ups

Must have complete name and address for all contacts. Emergency contact must be someone other than parents/guardians.
Contact Name*

First NameLast Name
Relation to Child*
Relation to Parent*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Work Number
Format: (000) 000-0000.
Home Number
Format: (000) 000-0000.
Cell Number*
Format: (000) 000-0000.
Emergency Pick-Up*

YesNo
Contact Name

First NameLast Name
Relation to Child
Relation to Parent
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Number
Format: (000) 000-0000.
Home Number
Format: (000) 000-0000.
Cell Number
Format: (000) 000-0000.
Emergency Pick-Up

YesNo
Contact Name

First NameLast Name
Relation to Child
Relation to Parent
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Number
Format: (000) 000-0000.
Home Number
Format: (000) 000-0000.
Cell Number
Format: (000) 000-0000.
Emergency Pick-Up

YesNo
**If you need to add more emergency contact/pick-up persons, please contact the front desk.**
Emergency Medical Information & Authorizations
If the following questions do not apply to your child, please type 'none' .
Child's Pediatrician*
Pediatrician's Phone Number*
Format: (000) 000-0000.
Pediatrician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Other Physicians or Specialists

Rows	Name of Physician	Speciality	Phone Number
Physician 1
Physician 2
Physician 3
Physician 4

List any Accidents/ Major Illnesses/ Operations*

Rows	Date	Age	Circumstance
1
2
3
4

Child's Diagnosis and/or Medical Conditions*

Child's Current Development*

Rows	Advanced	Within Normal Limits	Somewhat Delayed	Significantly Delayed
Communication/Language
Fine Motor
Gross Motor
Hearing
Self-help [feeding,dressing]
Social/Emotional
Vision

Notes about Child's Current Development*
If delays indicated, please provide details.

Medications [type none if not applicable] *

Rows	Medication Name	Dose	Frequency
Medication 1
Medication 2
Medication 3
Medication 4

Will medication be given during school hours?*

YesNoN/A

Regular Treatments

Rows	Frequency
Blood Sugar Monitor
Breathing Treatment
Catheterization
Oxygen Monitor
Tube Feed
Other

Does your child have a history of the following?*

SeziuresAsthmaBoth of the aboveNone of the above
If yes to the above question, does your child take emergency medicine? [List all]

Allergies*

Rows	Type of Allergy [ex. Peanut]	Reaction	Emergency Medication
Allergy 1
Allergy 2
Allergy 3

RISKS - Check all that apply*

NoneChokes EasilyG-TubeHeart ConditionShuntSkin BreakdownTires EasilyTracheotomyOther
EQUIPMENT -Check all that apply*

NoneGlassesHearing AidOrthosis [AFO,SMO]WalkerWheelchair/Personal StrollerOther
Is your child potty-trained?*

YesNoIn Progress
Except for first aid, personnel shall not dispense prescription or non-prescription medications to a child without specific written authorization from the child's physician or parent. Such authorization will include, when applicable, date; full name of the child; name of the medication; prescription number, if any; dosage; the dates to be given; the time of day to be dispensed; and signature of parent. I give Sisu permission to apply one or more of the following topical ointments/preparations to my child in accordance with the directions on the label of the container. [Baby Wipes, Cortizone 10 Cream, Latex Free Band Aids, Neosporin or Triple Antibiotic Ointment, Non-prescription Ointment [A&D, Vaseline, Aquaphor] and Sting Relief.]*

YesNo
Parent/Guardian Signature*
Today's Date

MonthDayYear
Date
Should my child suffer an injury or illness while in the care of Sisu and if I am unable to be reached immediately, I authorize the facility to secure such medical attention and care as necessary. Additionally, I authorize the transfer of health records to emergency care providers. I shall assume responsibility for payment for services.*

Yes, I have read and authorize the above statement.
Parent/Guardian Signature*
Today's Date

MonthDayYear
Date
Health Insurance Information
If the below questions do not apply to your child, please write 'none'.
Insurance Provider*
Policy Number
Image of Insurance Card
Enrollment Info
New or Returning Student?*

Returning StudentNew Student
Number of Years at Sisu
Please indicate below your desired schedule. Actual schedule is based on availabiliy and will be determined at intake appointment.
Early Arrival [7:00am - 8:30am]

MondayTuesdayWednesdayThursdayFriday
EEI Program [8:30am - 12:30pm]*

MondayTuesdayWednesdayThursdayFriday
Long Stay [12:30pm - 4:30pm]

MondayTuesdayWednesdayThursdayFriday
GA PreK [8:30am - 3:15pm]

MondayTuesdayWednesdayThursdayFriday
Short Stay [12:30pm - 2:00pm]

MondayTuesdayWednesdayThursdayFriday
GA PreK Ext. Day [3:15pm - 4:30pm]

MondayTuesdayWednesdayThursdayFriday
Therapy Services you would like to receive at Sisu

OTPTSTABA
Therapy Services your child currently receives outside of Sisu

OTPTSTABAOther
If child receives therapies outside of Sisu, please list location and therapist's name.
Did your child participate in Babies Can't Wait?*

YesNoCurrently Participating
Does your child receive services through a school system Individualized Education Plan (IEP)?*

YesNoIn ProcessReferral Needed
If you answered yes above, which school system serves your child's IEP?

Hall County SchoolsGainesville City SchoolsOther County
What is your child's home school district for K-5?
Parental Authorizations
Sisu utilizes an electronic communication tool to increase parent engagement. This program will allow our teachers to capture special moments, take photos, and videos of the children in action as well as send you classroom information directly to your email. We consider all information captured using a digital media to be a private communication between our school and our families. No personal information is shared with any external parties and as a parent you will only receive information specifically about your child.
*

I give permission for my child’s daily notes and photos to be sent to me electronically. I understand that I will not receive paper copies of these documentsI refuse permission for my child’s daily notes to be sent only via email and would like to receive a hard copy document.
Use of child information, photo or video image for community awareness, education purposes and public relations. Sisu may use the images and/or information of students to increase community awareness and educate the community on the services and programs of Sisu. We may use a child's first name and the personal characteristics that idenfity or describe the child and if applicable, the impact of his/her developmental delay or disability during agency tours, community exhibits and presentations. Sisu has a website, www.mysisu.org, that displays a variety of pictures that include children, staff, volunteers, and parents participating in daily programs, center events and agency fundraising events. Additionally, Sisu has other social media platforms, such as Facbeook and Instagram, that may include a child's image.
*

I give permission to take pictures or videos of my child to be used to increase community awareness and educate the community on the services and programs of Sisu. These pictures may be placed on the Sisu website and/or other social media platforms. Also, I give permission for Sisu to use my child’s first name and the personal characteristics that identify or describe the child and if applicable, the impact of his/her developmental delay or disability in community exhibits and presentations.I refuse permission for use of pictures or videos of my child for community awareness and marketing as well as the use of mychild’s information during tours, exhibits, presentation and/or any other form of marketing or public relations.
Each child receives a developmental assessment and ongoing tracking of student performance using the GELDS standards. Sisu uses a variety of assessment tools including the standardized Ages and Stages Questionnaire. The child’s classroom teacher can access the expertise of licensed speech pathologists, occupational and physical therapists. Our developmental assessments are not a medical checkup and do not determine IQ scores. It will guide us on whether your child is functioning within normal limits compared to other children of the same age, and help us plan activities based on your child’s strengths and weaknesses and unique characteristics.
*

I give my permission for my child to receive a developmental screening by the staff in order to track developmental progress. I understand that I will receive a copy of the screening results and periodic progress updates.I refuse permission for my child to receive a developmental screening by the staff. I understand that my child will not receive specific classroom goals and will not receive progress updates.
Each child receives a developmental assessment and ongoing tracking of student performance using the GELDS standards. Sisu uses a variety of assessment tools including the standardized Ages and Stages Questionnaire. The child’s classroom teacher can access the expertise of licensed speech pathologists, occupational and physical therapists. Our developmental assessments are not a medical checkup and do not determine IQ scores. It will guide us on whether your child is functioning within normal limits compared to other children of the same age, and help us plan activities based on your child’s strengths and weaknesses and unique characteristics.
*

I give permission for local school system staff and/or college and university students/interns to view records for purposes described above.I refuse permission for any other than Sisu staff to view my child’s records.
Each child receives a developmental assessment and ongoing tracking of student performance using the GELDS standards. Sisu uses a variety of assessment tools including the standardized Ages and Stages Questionnaire. The child’s classroom teacher can access the expertise of licensed speech pathologists, occupational and physical therapists. Our developmental assessments are not a medical checkup and do not determine IQ scores. It will guide us on whether your child is functioning within normal limits compared to other children of the same age, and help us plan activities based on your child’s strengths and weaknesses and unique characteristics.
*

I give my permission for my child to participate in Pet Therapy and other curricular activities or center events that may include animals.I refuse permission for my child to participate in Pet Therapy and other curricular activities or center events that may include animals.
Curriculum activities or center events may include water-related activities. Water related activities at Sisu have depth maximums of 2 inches for infants, 6 inches for toddlers and 12 inches (1 Ft) for preschoolers. Sisu uses the rules of our licensing authority, Bright from the Start, when conducting water-related activities.
*

I give my permission for my child to participate in water-related activitiesI refuse permission for my child to participate in water-related activities.
PARENT ACKNOWLEDGEMENTS*

I, as the custodial parent/guardian of the child enrolling in Sisu’s Early Education and Intervention Program, have read, understand and will abide by the policies and procedures that are included in both the Parental Agreement and Sisu Parent Handbook throughout the duration of said child’s enrollment in the program.I, as the custodial parent/guardian of the child enrolling in Sisu's Early Education and Intervention Program, have been offered, read and understand the Sisu Notice of Privacy Practices.
Parent/Guardian Signature*
Today's Date

MonthDayYear
Date

Sisu of Georgia, Inc. Registration Form

Child's Info

Parent/Guardian 1

Parent/Guardian 2

Emergency Contacts & Authorized Pick-Ups

Emergency Medical Information & Authorizations

Health Insurance Information

Enrollment Info

Parental Authorizations

Demographics

Survey