GLORIA DEI PRESCHOOL DISCOVERY CENTER
Gloria Dei Preschool 570 Welsh Road Huntingdon Valley, PA 19006 (215) 947 – 8653 [email protected]
STUDENT INFORMATION FORM PLEASE PRINT LEGIBLY & FULLY COMPLETE ALL INFORMATION
School Year 2017-2018
Child’s Name______________________________________________ DOB: ____________________
M____F____
Home Address _____________________________________ City _________________State __________Zip_________ Home Phone (____) _______ - ____________
Primary E-Mail __________________________________________
Father’s/ Legal Guardian Full Name ___________________________________ Cell Phone (____) _______ - ________ Father’s Home Address _____________________________ City _________________State ___________Zip_________ Father’s Occupation _________________ Employer _________________Work Phone (____) _______ - ___________ Employer’s Address/City/State/Zip _____________________________________________________________________ Mother’s/ Legal Guardian Full Name _____________________________________ Cell Phone (____) ______ - _______ Mother’s Home Address ______________________________ City _________________State __________Zip_________ Mother’s Occupation _________________ Employer _________________Work Phone (____) _______ - __________ Employer’s Address/City/State/Zip _____________________________________________________________________ Parent’s/Guardian Marital Status: Single ___ Married___ *both parent/guardian signatures required
*Separated ___
*Divorced ___
Domestic Partner ___
Siblings:
______________________________ Name
DOB
________________________________ ______________________________ Name
DOB
Name
DOB
______________________________
________________________________ _____________________________
Name
Name
DOB
DOB
Name
DOB
MEDICAL INFORMATION:* Name of Child’s Physician: __________________________________________Phone (____) _______ - ___________ Address ________________________________ City/State ________________________________ Zip _____________ Does your child have allergies? If yes, please list: ___________________________________________________________________________________ Is there any special medical, dietary, disabilities, medication or special needs information (info necessary in emergency situation)? If yes, please list ___________________________________________________________________________________ _________________________________________________________________________________________________ Health Insurance Coverage for child/Medical Assistance Benefits Policy Number Required
*EVERY STUDENT MUST BE FULLY IMMUNIZED AND HAVE A YEARLY CHECK UP WITH A FULLY COMPLETED AND SIGNED MEDICAL FORM ON FILE WITH OUR OFFICE BY SEPTEMBER 1, 2017.*
DEVELOPMENTAL HISTORY What is the primary language spoken at home? __________________ Secondary language? ______________________ Is your child currently being screened / evaluated, for physical, developmental, speech, or hearing services? No st If yes, please submit IEP prior to September 1 . Please indicate below how we can support your child. _________________________________________________________________________________________________ _________________________________________________________________________________________________
(PLEASE COMPLETE BACK OF APPLICATION)
EMERGENCY INFORMATION - PLEASE READ CAREFULLY IN CASE OF AN EMERGENCY AND PARENTS CANNOT BE REACHED, CONTACT THE FOLLOWING PEOPLE: PLEASE PROVIDE THE PHONE NUMBER WHERE THE PERSON CAN BEST BE REACHED DURING SCHOOL HOURS. THESE CONTACTS ARE ALSO PERSONS WHO YOUR CHILD MAY BE RELEASED TO IN YOUR ABSENCE AND WILL ALSO BE LISTED ON YOUR CHILD PICK UP AUTHORIZATION. (PROVIDE 2 CONTACTS OTHER THAN A CHILD’S PARENTS/ LEGAL GUARDIANS)
1. Name ____________________________ Relationship to child_______________ Phone (____) _______ - ___________ Address/City/State/Zip_________________________________________________________________________________ 2. Name ____________________________ Relationship to child_______________ Phone (____) _______ - ___________ Address/City/State/Zip_________________________________________________________________________________ Please check your current status:
Present Family
Gloria Dei Church Member
New Family
Former Family
PLEASE READ, CHECK OFF THE APPROPRIATE BOXES, AND SIGN THE FOLLOWING PARENT PERMISSIONS: PARENT HANDBOOK ACKNOWLEDGEMENT: I HAVE READ AND FULLY UNDERSTAND THE PARENT HANDBOOK FROM GLORIA DEI PRESCHOOL. I WILL ABIDE BY THE GUIDELINES AS STATED IN THE HANDBOOK. ES PICTURE PERMISSION: AT TIMES WE PUBLISH PICTURES OF STUDENTS ON OUR WEBSITE, IN MONTHLY NEWSLETTERS, ON FACEBOOK, AND/OR OUR BROCHURE. I GIVE MY PERMISSION FOR PICTURES IN WHICH MY CHILD MAY BE PRESENT TO BE PUBLISHED. STUDENT DIRECTORY INFORMATION: I GIVE PERMISSION FOR MY ADDRESS, TELEPHONE AND E-MAIL INFORMATION TO BE PUBLISHED IN THE STUDENT DIRECTORY. I UNDERSTAND THIS INFORMATION WILL NOT BE USED FOR SOLICITATION PURPOSES. ES NO I GIVE PERMISSION FOR MY CHILD TO PARTICIPATE IN OUTDOOR WALKS AND TRIPS. PLEASE SIGN: MEDICAL TREATMENT & ADMINISTRATION OF MINOR FIRST-AID PROCEDURES: I HEREBY GIVE THE AUTHORITIES OF GLORIA DEI CHURCH AND/OR GLORIA DEI PRESCHOOL DISCOVERY CENTER, MY CONSENT FOR MEDICAL TREATMENT, INCLUDING ADMINISTRATION OF MINOR FIRST-AID PROCEDURES, FOR MY SAID SON/DAUGHTER IN THE EVENT OF A MEDICAL EMERGENCY, WHILE MY SAID CHILD IS UNDER THE CARE AND CONTROL OF EITHER SAID ORGANIZATION. PLEASE SIGN:
INTERNET POLICY:
ES, I GIVE PERMISSION FOR MY CHILD TO USE THE INTERNET FOR EDUCATIONAL PROGRAMS. I UNDERSTAND THAT MY CHILD WILL BE SUPERVISED BY PRESCHOOL STAFF AND NOT PERMITTED TO VENTURE ON THE INTERNET AND UNAPPROVED SITES. *NO, I DO NOT GIVE PERMISSION FOR MY CHILD TO USE INTERNET BASED PROGRAMS *I UNDERSTAND THAT BY MY CHILD WILL NOT BE PERMITTED ACCESS TO THE CLASSROOM COMPUTERS WHEN INTERNET BASED PROGRAMS ARE BEING USED.
PARENT/ LEGAL GUARDIAN SIGNATURE UPON REGISTRATION
___________________________________________________________________
EFFECTIVE DATE
9/01/2017
PARENT/LEGAL GUARDIAN SIGNATURE UPON PERIODIC (6 MONTH) REVIEW
___________________________________________________________________
DATE______________________
OPTIONAL CLIENT INFORMATION REPORTED YEARLY TO DPW: (PLEASE CHECK APPROPRIATE BOX FOR CHILD BELOW) White Hispanic Asian/Pacific Islander Other
STUDENT INFORMATION FORM PLEASE PRINT LEGIBLY & FULLY COMPLETE ALL INFORMATION
School Year 2017-2018
Child’s Name______________________________________________ DOB: ____________________
M____F____
Home Address _____________________________________ City _________________State __________Zip_________ Home Phone (____) _______ - ____________
Primary E-Mail __________________________________________
Father’s/ Legal Guardian Full Name ___________________________________ Cell Phone (____) _______ - ________ Father’s Home Address _____________________________ City _________________State ___________Zip_________ Father’s Occupation _________________ Employer _________________Work Phone (____) _______ - ___________ Employer’s Address/City/State/Zip _____________________________________________________________________ Mother’s/ Legal Guardian Full Name _____________________________________ Cell Phone (____) ______ - _______ Mother’s Home Address ______________________________ City _________________State __________Zip_________ Mother’s Occupation _________________ Employer _________________Work Phone (____) _______ - __________ Employer’s Address/City/State/Zip _____________________________________________________________________ Parent’s/Guardian Marital Status: Single ___ Married___ *both parent/guardian signatures required
*Separated ___
*Divorced ___
Domestic Partner ___
Siblings:
______________________________ Name
DOB
________________________________ ______________________________ Name
DOB
Name
DOB
______________________________
________________________________ _____________________________
Name
Name
DOB
DOB
Name
DOB
MEDICAL INFORMATION:* Name of Child’s Physician: __________________________________________Phone (____) _______ - ___________ Address ________________________________ City/State ________________________________ Zip _____________ Does your child have allergies? If yes, please list: ___________________________________________________________________________________ Is there any special medical, dietary, disabilities, medication or special needs information (info necessary in emergency situation)? If yes, please list ___________________________________________________________________________________ _________________________________________________________________________________________________ Health Insurance Coverage for child/Medical Assistance Benefits Policy Number Required
*EVERY STUDENT MUST BE FULLY IMMUNIZED AND HAVE A YEARLY CHECK UP WITH A FULLY COMPLETED AND SIGNED MEDICAL FORM ON FILE WITH OUR OFFICE BY SEPTEMBER 1, 2017.*
DEVELOPMENTAL HISTORY What is the primary language spoken at home? __________________ Secondary language? ______________________ Is your child currently being screened / evaluated, for physical, developmental, speech, or hearing services? No st If yes, please submit IEP prior to September 1 . Please indicate below how we can support your child. _________________________________________________________________________________________________ _________________________________________________________________________________________________
(PLEASE COMPLETE BACK OF APPLICATION)
EMERGENCY INFORMATION - PLEASE READ CAREFULLY IN CASE OF AN EMERGENCY AND PARENTS CANNOT BE REACHED, CONTACT THE FOLLOWING PEOPLE: PLEASE PROVIDE THE PHONE NUMBER WHERE THE PERSON CAN BEST BE REACHED DURING SCHOOL HOURS. THESE CONTACTS ARE ALSO PERSONS WHO YOUR CHILD MAY BE RELEASED TO IN YOUR ABSENCE AND WILL ALSO BE LISTED ON YOUR CHILD PICK UP AUTHORIZATION. (PROVIDE 2 CONTACTS OTHER THAN A CHILD’S PARENTS/ LEGAL GUARDIANS)
1. Name ____________________________ Relationship to child_______________ Phone (____) _______ - ___________ Address/City/State/Zip_________________________________________________________________________________ 2. Name ____________________________ Relationship to child_______________ Phone (____) _______ - ___________ Address/City/State/Zip_________________________________________________________________________________ Please check your current status:
Present Family
Gloria Dei Church Member
New Family
Former Family
PLEASE READ, CHECK OFF THE APPROPRIATE BOXES, AND SIGN THE FOLLOWING PARENT PERMISSIONS: PARENT HANDBOOK ACKNOWLEDGEMENT: I HAVE READ AND FULLY UNDERSTAND THE PARENT HANDBOOK FROM GLORIA DEI PRESCHOOL. I WILL ABIDE BY THE GUIDELINES AS STATED IN THE HANDBOOK. ES PICTURE PERMISSION: AT TIMES WE PUBLISH PICTURES OF STUDENTS ON OUR WEBSITE, IN MONTHLY NEWSLETTERS, ON FACEBOOK, AND/OR OUR BROCHURE. I GIVE MY PERMISSION FOR PICTURES IN WHICH MY CHILD MAY BE PRESENT TO BE PUBLISHED. STUDENT DIRECTORY INFORMATION: I GIVE PERMISSION FOR MY ADDRESS, TELEPHONE AND E-MAIL INFORMATION TO BE PUBLISHED IN THE STUDENT DIRECTORY. I UNDERSTAND THIS INFORMATION WILL NOT BE USED FOR SOLICITATION PURPOSES. ES NO I GIVE PERMISSION FOR MY CHILD TO PARTICIPATE IN OUTDOOR WALKS AND TRIPS. PLEASE SIGN: MEDICAL TREATMENT & ADMINISTRATION OF MINOR FIRST-AID PROCEDURES: I HEREBY GIVE THE AUTHORITIES OF GLORIA DEI CHURCH AND/OR GLORIA DEI PRESCHOOL DISCOVERY CENTER, MY CONSENT FOR MEDICAL TREATMENT, INCLUDING ADMINISTRATION OF MINOR FIRST-AID PROCEDURES, FOR MY SAID SON/DAUGHTER IN THE EVENT OF A MEDICAL EMERGENCY, WHILE MY SAID CHILD IS UNDER THE CARE AND CONTROL OF EITHER SAID ORGANIZATION. PLEASE SIGN:
INTERNET POLICY:
ES, I GIVE PERMISSION FOR MY CHILD TO USE THE INTERNET FOR EDUCATIONAL PROGRAMS. I UNDERSTAND THAT MY CHILD WILL BE SUPERVISED BY PRESCHOOL STAFF AND NOT PERMITTED TO VENTURE ON THE INTERNET AND UNAPPROVED SITES. *NO, I DO NOT GIVE PERMISSION FOR MY CHILD TO USE INTERNET BASED PROGRAMS *I UNDERSTAND THAT BY MY CHILD WILL NOT BE PERMITTED ACCESS TO THE CLASSROOM COMPUTERS WHEN INTERNET BASED PROGRAMS ARE BEING USED.
PARENT/ LEGAL GUARDIAN SIGNATURE UPON REGISTRATION
___________________________________________________________________
EFFECTIVE DATE
9/01/2017
PARENT/LEGAL GUARDIAN SIGNATURE UPON PERIODIC (6 MONTH) REVIEW
___________________________________________________________________
DATE______________________
OPTIONAL CLIENT INFORMATION REPORTED YEARLY TO DPW: (PLEASE CHECK APPROPRIATE BOX FOR CHILD BELOW) White Hispanic Asian/Pacific Islander Other
