Chappell Schools - Registration Packet
Chappell Schools Registration Packet
Center
Enrollment Date
Start Date
Child's Information
Child's Name
Child's Date of Birth
Address
Name Child Prefers
Please List any medical conditions, medication and or any special attention your child many require in the box below.
Comments
Allergies
Pediatrician's Name
Pediatrician's Number
Pediatrician's Address
Parent/Guardian Information
Mother/Guardian
Name
Address
Input ID Number
Cell Phone Number
Office Number
Employed By
Work Address
Are You The Custodial Parent (If Married Both May Check)
Door Code
Father/Guardian
Name
Address
Input ID Number
Cell Phone Number
Office Number
Employed By
Work Address
Are You The Custodial Parent (If Married Both May Check)
Door Code
Emergency Contacts
Child may be released only to the custodial parent, legal guardian or persons listed below with picture identification. If the custodial parent or legal guardian can not be reached, the person below will be contacted and are authorized to remove the child from the facility in case of illness, accident or emergency.
Name
Phone
Relationship
Name
Phone
Relationship
Name
Phone
Relationship
Name
Phone
Relationship
Name
Phone
Relationship
Medical Treatment
As parent/legal guardian, I give consent to for my child to receive by Chappell Schools staff and if necessary be transfered to receive emergency care. In case of emergency I as the parent or legal guardian of my child do hold Chappell Schools harmless of any illness/injury. I understand that I am responsible for such treatment. I understand that I will be responsible for all charges not covered by insurance. I agree to review and update this information whenever a change occurs at least once a year. I understand I will be given student accident claim forms should an incident occur. I understand that this paper work MUST be submitted within 30 days in order to open a claim for pending charges.
Immunization Requirements
All children enrolled in our schools must have a current Florida Immunization Certificate and an updated physical on file at our schools at all times. Parents are given 30 days from the date of enrollment to provide this at the front desk. Once the initial 30 days has expired the child is not allowed to continue attending our schools.
By signature you verify that all information on this enrollment form is correct and accurate. Your signature also verifies the receipt of the following: nnParent HandboooknDisciplinary Expulsion Policyn"Know Your Child Care Center" Dept. of Children and Families Publication.nAuthorization For Medication PolicynCollection Disclaimer: As parent or legal guardian you are responsible for all charges made and or pending during period of enrollment and at the time of dismissal.
Name
Date
What Makes My Child Special
Child's Name
DOB
Age
Previsously my child was cared for:
My Child Lives with:
Any Siblings?
If you Answered yes to the previous question. Please state their names and ages in the fields below.
Name
Age
Name
Age
Name
Age
I would say his day was relatively:
In new situations my child tends to:
What is the primary language spoken at home:
Is he or she potty trained?
Sleeping
Does your child sleep with special items i.e. dolls, or blankets?
Special Hints to help at nap time:
Learning and Fun
Likes to do the following activities
My child can't part with (toys, dolls, etc.)
Others
If yes please list their names here.