If there is an emergency and I cannot be reached, I hereby grant permission for
Golden. Book Pre-School Staff or employees of Golden Book Pre-School to ...
Golden Book Pre-School Enrollment Application Entrance Date:
Medication Information If there is an emergency and I cannot be reached, I hereby grant permission for Golden Book Pre-School Staff or employees of Golden Book Pre-School to contact the following medical personnel to obtain emergency medical care if warranted.
Doctor:
Address: ----------------
Phone:
Hospital Preference:
_
Medical Insurance & Policy Number:
_
Waiver of Liability: In case of accident of illness: should my child become ill or suffer an accident of any kind during the time that he/she is in the care of Golden Book PreSchool, the school shall attempt to reach me immediately. In the event the school is unable to reach me immediately, it shall be authorized to secure such medical attention and care first from the physician or preferred hospital listed above and then from any duty licensed physician selected by the school. I understand that I am responsible for any and all fees incurred and agree to assume responsibility for payment of such. Primary Contact for any concerns regarding your child:
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Please List any Allergies-
May mother remove child?
Yes -----
No
_
May father remove child?
Yes -----
No.
_
Others who are permitted to remove child?
Please list at least two persons to be notified in case of Illness/Accident if parents are unavailable. In case of an emergency, a local phone number must be available.
Name:
Home/Cell Phone: -------
Address: -----------------------Relationship:
Name: -------------------------
_
Home/Cell Phone:
------
Address: -----------------------Relationship:
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Page 3
•
Golden Book Pre-school may use Photographs of my child for newspaper articles, the School website, brochures, or publicity purposes.
Yes ------
No ------
•
Section 65C-22.006 (4) 2 F.A.C. requires that parents are notified in writing of the disciplinary practices used by the childcare facility.
•
Section 65C-22.006 (2) F.A.C. requires a current physicalexarnination (Yellow Form) and Immunization record (Blue form 60 or 681) within 30 days of enrollment.
•
Section 402.3125 (5) FS requires that parents receive a copy ofthe child care Facility Brochure - "Know Your Child Care Facility."
By signing below you verify that you have received the above items and that all information on this enrollment form is complete and accurate. Parents or Legal Guardians are required to disclose any physical, emotional, or behavioral limitations, needs or concerns about their child in writing prior to registration. Golden Book Preschool reserves the right to deny registration or withdraw your child if it is determined our program is not suited or staffed to meet your child's needs. Golden Book Pre-school does not discriminate enrollment based upon race, color, sex, age, religion, disability, national or ethnic origin, or citizenship status. I have read the Golden Book Pre-school Handbook. I understand the information and agree to abide by the policies and procedures described therein.
