Lancaster Enrollment
Returning Powerhouse Family? (any campus)
Yes
No
Campus
*
When is your child's first day of Powerhouse?
*
-
Month
-
Day
Year
Date
Parent Information
Parent's Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
*
-
Area Code
Phone Number
Cell Phone Number
*
-
Area Code
Phone Number
Parent's Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
-
Area Code
Phone Number
Cell Phone Number
-
Area Code
Phone Number
Child's Living Arrangements
*
Both Parents
Mother
Father
Other (Specify)
Who is the child's Legal Guardian?
*
Child's Information
Child's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Grade
*
Program child will be attending (choose all that apply)
*
Morning
Afternoon
Extended Care
Number of days your child will attend
*
Full-Time (3-5 days a week)
Part-Time (1-2 days a week)
Are your records on file
*
My child’s immunization record is on file at the school and all required immunizations and/or tuberculosis test are current. Vision and hearing screening records are also on file.
Permission for your child
My child has permission to be released to the care of his/her sibling(s) that is between the age of 13 to 18 years old.
Name of sibling(s)
Age:
Emergency Contact & Authorized Pick Up Information
Whom should we contact when Parent/Guardian is not available? Please designate each person as an Emergency Contact, Authorized Pick Up, or both and their relationship to the child, along with telephone number. Children will only be released from the premises with a parent/guardian or a person designated by the parent/guardian after verification of ID.
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship to Child
*
Authorization
*
Emergency Contact
Authorized Pick-Up
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship to Child
Authorization
Emergency Contact
Authorized Pick-Up
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship to Child
Authorization
Emergency Contact
Authorized Pick-Up
Authorization for Emergency Medical Attention
In the event I cannot be reached to make arrangements for emergency medical care, I authorize the person in charge to take my child to:
Name of Physician
*
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Facility
*
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Consent
*
I give consent for the facility to secure any and all necessary emergency medical care for my child.
Signature of Parent or Legal Guardian
*
List any special needs/problems that your child may have such as ADD, ADHD, Autism, allergies, existing illness, previousserious illness, disabilities, injuries and hospitalizations during the past 12 months, any medication prescribed for long-termcontinuous use, and any other information which caregivers should be aware of:
*
Communication
Powerhouse communicates to parents in several different ways: face to face, notices sent home, by telephone, Facebook,email and text messaging. Please be sure we have your correct information so we may communicate with you effectively.
Phone Number
*
-
Area Code
Phone Number
Network Carrier
*
Email
*
example@example.com
Other Authorizations
Is your student in foster care?
*
Yes
No
If student is not in foster care, images of student may be captured during regular and special activities through videos and photographs. Videos and photographs will be used solely for the purposes of promoting Powerhouse through flyers, publications, social media, and/or web site.
Tuition Responsibility
*
I understand that tuition is charged every Friday for the following week of care and I am responsible to pay for the amount charged regardless of attendance to reserve my child’s spot. I understand that failure to pay could result in automatic withdraw from Powerhouse and my spot given to a family waiting for care.
Signature of Parent or Legal Guardian
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: