Registration Packet 2011-2012
Registration Packet 2011-2012
Registration Packet 2011-2012
Dear Parents,
Please take the time to fill out the 2011-2012 registration packet,
submit it with your $55.00 registration fee and applicable activity
fee (fees differ for each class) to hold your child’s place in the
Weekday School. Open spaces are filled on a first come, first
served basis. In order to assure your child’s place in the Weekday
School, it is recommended that you submit the registration forms
and fees as soon as possible.
*Monthly tuition for the 4’s and Stepping Stones Class includes Play Spanish tuition.
To confirm your child’s place in the Weekday School, both the non-refundable
Registration Fee and the non-refundable Activity Fee must be paid at the time of
registration. The Activity Fee will include everything except Scholastic book orders,
Pennies from Heaven, t-shirt sales, pictures and our 2 fundraisers (all optional). For field
trips including parents, these fees cover the cost of one parent. They also include a
Handwriting Without Tears Workbook (3s, 4s & SS) for your child and a monthly
subscription to Scholastic magazine (4s & SS).
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Address ________________________________________________________________
Address ________________________________________________________________
PHYSICAL EXAMINATION
(Must be completed and signed by the examining physician)
Recommendations: ___________________________________________
VACCINE #1 #2 #3 #4 #5
DTP/DT
Polio xxxxxxxxx
HiB xxxxxxxxx
Hepatitis B xxxxxxxxxx xxxxxxxxx
MMR xxxxxxxxxx xxxxxxxxxx xxxxxxxxx
Chicken Pox
Prevnar
Other
_________________________________________
________________________
Physician’s Signature Date of Examination
_________________________________________
________________________
Office Address Telephone Number
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Medical History
1. Is your child allergic to anything? Yes _____ No _____
If so, what? ________________________________________________________
2. Has your child had a serious illness, surgery or hospital stay? Yes _____ No _____
If so, please describe: ________________________________________________
3. Does your child have any physical handicaps? Yes _____ No _____
If so, please describe: ________________________________________________
4. Is your child currently under the care of a Doctor? Yes _____ No _____
If so, for what reason? _______________________________________________
Medical Information
I agree that the director may authorize the physician of his/ her choice to provide
emergency care in the event that neither the family physician nor I can be contacted
immediately. This is done with the understanding that every attempt will have been
made to contact the parents, the child’s physician and other persons listed for emergency
contact.
______________________
__________________________________________
Date Signature of parent or guardian
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Initial
Address ______________________________________________________
_____________________________________________________________
City State Zip Code
In case of emergency, please list two people who can be contacted if you cannot be reached.
Name of person(s) that are allowed to pick-up Child on regular basis _____
_____________________________________________________________
_____________________________________________________________
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We ask that each child in the 3, 4-year old and Stepping Stones classes
purchase a school t-shirt. These will be worn on field trips. Everyone is welcome
to purchase a shirt. We have adult sizes too! The t-shirt order form is below and
should be returned with registration fees. Returning students that already have t-
shirts do not need to purchase new ones unless they would like to. Thank you in
advance.