**2024-2025 Pre-K Registration [Complete Packet]

Pre-K Registration Form
CHILD INFORMATION

(Please print name exactly as it appears on the birth certificate)
Name*

CHILD’S FIRST NAMECHILD’S LAST NAME
CHILD’S MIDDLE NAME
NAME SUFFIX
(Ex: Jr., Sr., II, or III)
CHILD’S SOCIAL SECURITY#*
D.O.B. (MM/DD/BY)*

MonthDayYear
Date
Sex:*

MaleFemale
Race*

AsianBlack -or- African AmericanHawaiian -or- Pacific IslanderNative American -or- IndigenousWhite
Ethnicity*

Hispanic/LatinoNot Hispanic
HOME ADDRESS*
CITY*
STATE*
Ex: Georgia = GA
ZIP*
HOME PHONE*
If the Student is transferring from another PreK, please provide the following
Previous School Name
Last Date in Attendance

MonthDayYear
Date
PARENT/GUARDIAN INFORMATION
Parent/Guardian #1
FIRST NAME*
LAST NAME*
MIDDLE INITIAL
Home Address (If different from child)
City
State
Zip
Home Phone
Cell Phone*
Email Address*
example@example.com
Place of Employment*
Enter "N/A" if unemployed
Work Phone
Employment Address
City
State
Zip
Parent/Guardian #2
FIRST NAME
LAST NAME
MIDDLE INITIAL
Parent/Guardian #2 Home Address (If different from child)
City
State
Zip
Home Phone
Cell Phone
Email Address
example@example.com
Place of Employment
Enter "N/A" if unemployed
Work Phone
Employment Address
City
State
Zip
EMERGENCY CONTACT INFORMATION (Persons to contact in the event that either parent/guardian cannot be contacted)
Emergency Contact #1
Name | Relationship | Cell Phone
Emergency Contact #2
Name | Relationship | Cell Phone
I verify the above information to be correct, and I understand that completion of this form does not guarantee placement in a Pre-K class. If my child is placed in Georgia's Pre-K Program, I agree that my child will attend the program for the required number of hours and days as prescribed by the Georgia Department of Early Care and Learning and outlined by the center where my child is enrolled. I understand that failure to comply with these attendance requirements could result in disenrollment. I understand that I cannot register my child without appropriate age documentation. I have attached a copy of appropriate age documentation to this registration form.
Signature Parent/Guardian*

Clear
DATE*

MonthDayYear
Date
Child's Living Arrangements*

Both ParentsMotherFatherOther
Child's Legal Guardian*

Both ParentsMotherFatherOther
THE CHILD MAY BE RELEASED TO THE PERSON(S) SIGNING THIS AGREEMENT OR TO THE FOLLOWING:
Authorized Pick-up #1
Name | Address | Relationship | Cell Phone
Authorized Pick-up #2
Name | Address | Relationship | Cell Phone
Authorized Pick-up #3
Name | Address | Relationship | Cell Phone
Authorized Pick-up #4
Name | Address | Relationship | Cell Phone
CHILD’S MEDICAL INFORMATION:
CHILD'S PHYSICIAN -or- CLINIC NAME*
DATE OF LAST FULL HEALTH SCREENING

MonthDayYear
Date
PHONE*
MY CHILD HAS THE FOLLOWING SPECIAL NEED(S):
THE FOLLOWING SPECIAL ACCOMMODATION(S) MAY BE REQUIRED TO MOST EFFECTIVELY MEET MY CHILD’S
NEEDS WHILE AT THIS CENTER:
MY CHILD IS CURRENTLY ON MEDICATION(S) PRESCRIBED FOR LONG-TERM CONTINUOUS USE AND/OR HAS
THE FOLLOWING PRE-EXISTING ALLERGIES, ILLNESS, OR HEALTH CONCERNS:
GENERAL RELEASE
I verify the above information to be correct and true. I hereby grant permission for the information provided in the preceding Registration Form to be distributed to Pre-K providers, the Department of Early Care and Learning (DECAL), and certain agencies or those entities contracted by Pre-K providers or DECAL which shall include, but not be limited to, the Georgia Department of Education, and colleges/universities.
PHOTOGRAPH/VIDEOTAPE RELEASE
Child's Name
First & Last Name
I hereby grant permission for the Pre-K provider specified below, the Georgia Department of Early Care and Learning (DECAL) and certain agencies or entities contracted by the Pre-K provider or DECAL which shall include, but not be limited to, the Georgia Department of Education, and colleges/universities, to record the participation and appearance of my child, [CHILD'S NAME] , by photograph and/or videotape in connection with daily Pre-K activities for the purposes of news releases, reporting, and assessing the progress of children and the program. DECAL and its contractors are authorized to exhibit or distribute such photograph(s) and/or videotape in whole or in part without restrictions or limitations for any educational or promotional purpose that DECAL deems appropriate. Such photograph(s) and/or videotape may, for example, appear in printed or visual materials for DECAL and/or on DECAL’s web site.

The undersigned hereby jointly and severally releases, acquits, forgives, and discharges the Pre-K provider, DECAL, and other entities contracted by the Pre-K provider or DECAL, from any actions, agreements, claims, controversies, demands, judgments, liabilities, proceedings, and suits, whether arising in equity or in law regarding such participation and appearance by said child.

This release shall remain binding upon all successors in interest and personal representatives of the parties, to the extent permitted by law.

High Hope Academy | 2732 Central Ave S. #F, Tifton, GA 31794
Vehicle Emergency Medical Information
Mother's Name (Guardian 1) *
First & Last Name
Mother's (Guardian 1) Cell Phone*
Please enter a valid phone number.
Mother's (Guardian 1) Alt. Phone
Please enter a valid phone number.
Father's Name (Guardian 2)
First & Last Name
Father's (Guardian 2) Cell Phone
Please enter a valid phone number.
Father's (Guardian 2) Alt. Phone
Please enter a valid phone number.
Bright from the Start: Georgia Department of Early Care and Learning

CACFP Meal Benefit Income Eligibility Statement
Name of Child Care Center*
High Hope Academy
PART I: Child(ren) or Adult enrolled to receive day care
Child 1 Name: (Last, First and Middle Initial)*
Child 1 Birthdate*

MonthDayYear
Date
Child 2 Name: (Last, First and Middle Initial)
Child 2 Birthdate

MonthDayYear
Date
Child 3 Name: (Last, First and Middle Initial)
Child 3 Birthdate

MonthDayYear
Date
Child 4 Name: (Last, First and Middle Initial)
Child 4 Birthdate

MonthDayYear
Date
Child 5 Name: (Last, First and Middle Initial)
Child 5 Birthdate

MonthDayYear
Date

Children in Head Start, foster care and children who meet the definition of migrant, runaway, or homeless are eligible for free meals. Check (✓) all that apply.

	Head Start	Foster Child	Migrant	Runaway	Homeless
Child 1
Child 2
Child 3
Child 4
Child 5

PART II: Report Income for ALL Household Members

(Skip this step if participant is categorically eligible as documented in Part I)

A. Child Income - Sometimes children in the household earn or receive income. Please indicate the TOTAL income received by child household members listed in PART I here.
Total Child Income
How often?
B. Other Household Members.
- List all household members that were not previously listed on the form even if they do not receive income.
- For each Household Member listed, if they do receive income, report total gross income (before taxes) for each source in whole dollars (no cents) only.
- If they do not receive income from any source, write ‘0’. If you enter “0” or leave any field blank you are certifying (promising) there is no income to report.
- FOR ADULT DAYCARES: List the adult participant if he/she did not meet eligibility in Part I.

Name of Other Household Members (First and Last)

	Name of Other Household Members (First and Last) (Ex: Brown, Charlie)	1. Earnings from work before deductions/ How often? (Ex: $500/Weekly)	2. Welfare, child support, alimony/ How often? (Ex: $800/Monthly)	3. Social Security, Pensions, Retirement/ How often?(Ex: $400/Monthly)	4. All other income/ How often? (Ex: $300/Monthly)
1.
2.
3.
4.
5.

C. Total # of Household Members (Adults and Children) listed in Part I and Part II
Social Security Number. If income is listed or completed in Part II, the adult completing the form must also list the last four digits of his or her Social Security Number or check the “I don’t have a Social Security Number” box below. (See Privacy Act Statement on next page). Failure to complete this section, if income is listed, will result in the denial of free or reduced eligibility.
Last four digits of Social Security Number *
Type "XXXX" if you do not have a Social Security Number
(✓) Check if you do not have a Social Security Number

I do not have a Social Security Number
Part III: Enrollment Information: Children Only
Arrival Time*

Center Open Time Minutes

AM/PM Option
Pick Up Time*

Center Closing Time Minutes

AM/PM Option
(✓) Check here if only before/after school care is provided.

Only enrolled in After School Care
Check the days your child will normally attend the center:*

MondayTuesdayWednesdayThursdayFriday
Check the meals your child will normally receive while in care:*

BreakfastAM SnackLunchPM Snack
Part IV: Signature
I certify that all information on this form is true and that all income is reported. I understand that the center or day care home will get Federal funds based on the information I give. I understand that CACFP officials may verify the information. I understand that if I purposefully give false information, the participant receiving meals may lose the meal benefits, and I may be prosecuted. This signature also acknowledges that the child(ren) or adult listed on the form in Part I are enrolled for care. If not completed fully and signed, the participant will be placed in the Paid category.

Signature auto-populates (Parent/Guardian 1) from earlier signature request on form
Part V: Participant's Ethnic & Racial Identities

Answers Auto-populate from earlier questions on form
Transportation Agreement
I permit High Hope Academy to transport my child for school related outings on the following days (please select all)

MondayTuesdayWednesdayThursdayFriday
Child Document Submission
Child's Social Security Card (SSN)

Cancelof
Proof of Age

Ex: birth certificate, passport, hospital record of live birth, green card, pink card or Federal I-94 card
Cancelof
Proof of Residency

Ex: utility bill, rental/mortgage agreement or letter from employer
Cancelof
Immunizations (DHR Form 3231)

Cancelof
Hearing, vision and dental examination certificates (DHR Form 3300)

Cancelof
Should be Empty:

Pre-K Registration Form

CHILD INFORMATION

PARENT/GUARDIAN INFORMATION

CHILD’S MEDICAL INFORMATION:

THE FOLLOWING SPECIAL ACCOMMODATION(S) MAY BE REQUIRED TO MOST EFFECTIVELY MEET MY CHILD’S

MY CHILD IS CURRENTLY ON MEDICATION(S) PRESCRIBED FOR LONG-TERM CONTINUOUS USE AND/OR HAS

GENERAL RELEASE

PHOTOGRAPH/VIDEOTAPE RELEASE

Vehicle Emergency Medical Information

Bright from the Start: Georgia Department of Early Care and Learning

Part IV: Signature

Part V: Participant's Ethnic & Racial Identities

Transportation Agreement

Child Document Submission