Little Bear Enrollment Form

Please fill out the form below and then print it with all the information you provided
or you may print the blank form and fill it out by hand.
Sign it and return it to the school with the other *required documents.
(* See the Parent Checklist )
Beginning Date:   Processing Date:  


Child's First Name: Middle Initial:
Last Name: Preferred Name:


Guardian 1:

Address:

City
   Zip: 

Home Phone:  
Work Phone:   
Place of Employment:
  
Work Address:
  
Social Security #:       
Birth Date:  
Driver's Lic. #:  
 Guardian 2:

Address:

City
   Zip: 

Home Phone:  
Work Phone:   
Place of Employment:
  
Work Address:
  
Social Security #:       
Birth Date:  
Driver's Lic. #:  
Please provide your schedule:
Monday:

Time: 		Tuesday:

Time: 		Wednesday:

Time: 		Thursday:

Time:
Friday:  
Time:   		Saturday:  
Time:   		Sunday:  
Time:<  





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Please provide the name, address, and telephone number of an adult who can assume responsibility for your child and who is authorized to take the child from LittleBear Preschool if the parent(s) cannot be reached:

Name:
Address:
Phone:
Relationship to the child:
Name:
Address:
Phone:
Relationship to the child:
Name:
Address:
Phone:
Relationship to the child:
Name:
Address:
Phone:
Relationship to the child:

If applicable, please provide us with the names of anyone who is not authorized to take the child from Little Bear, or, who is not authorized to have contact with the child:

Name:         Name:  

Name:         Name:  
Family History

1. With whom does your child live? (choose one)   

Other:  
2. If the child is living with one parent, does he/she see the other parent?   

Explanation:   

Is there any legal information the center needs to know regarding custody or visitation, etc. If so, please explain. (Include a copy of any restraining orders, court orders denying visitation, etc. with this form.)





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3. Please list all siblings, their ages, and if they live in the home with the child
Name Age Live in Home

If there are additional siblings, please list them on the back of this form after you print it out.
Please list all other adults or children living in the home

Name Relationship Age (Optional)

4. Describe your child's areas of need as you see them (i.e. educational or emotional needs):

5. Please share any additional comments you would like to make about your child


CHILD HEALTH


1. Does your child have any chronic health problems? If so, please describe


2. Does your child have any allergies? If so, please describe

3. Does your child take any medications on a routine basis?
Medication
Reason for Taking

4. Does your child have any physical needs that center staff need to be aware of? If so, please describe:







EMERGENCY CARE: I give permission to Little Bear staff to obtain emergency medical care for my son/daughter, .
(input child's name)

If a physician or hospital services are needed, I request that the following doctor be contacted if at all possible:
Doctor's Name:  
Phone:
Address:  


Parent Signature:_______________________________________________________________________

Date:_______________________________



Transportation Permission Slip


Child's Name:      Date:  


     I,   (your name),
parent/legal guardian of  (child's name), Hereby give permission to the authorized staff of Little Bear Preschool and Childcare, to transports my child in the van for field trips, and fo rmy child to go on walming field trips with the staff of Little Bear Preshool and Childcare facility.


Parents' Signature:_________________________________


Sun Block Permission Slip


     I,   (your name), hereby give Little Bear Preschool permission to apply my sunblock that I brought from home on my child, (child's name), before going outside each day.

Parent's Signature:________________________________________   Date:__________________________