SMALL MEADOWS PREschool
Small Meadows
REGISTRATION FORM for Preschool and or Summer Program
Child’s Full Name: ______________________________________________
Child’s Nickname: ______________________________________________
Date of Birth: __________________________________________________
Child’s Home Address: __________________________________________
______________________________________________________________
Tell us a little about your child’s interests and hobbies: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Mother’s/Guardian’s Information
Mother’s/Guardian’sName: ______________________________________
Mother’s Phone Numbers: ______________________________________
Mobile:______________________ Home: __________________________
Email Address:________________________________________________
Father’s/Guardian’s Information
Father’s/Guardian’s Name: ____________________________________
Father’s Phone Numbers: _____________________________________
Mobile: ____________________ Home: _________________________
Email Address: ______________________________________________
Child Release Information:
No child may be released from the preschool other than to his/her parents/guardian or a person designated in writing to receive the child. Those people authorized to pick-up the child will be required to present photo identification until such time as the staff easily recognizes them.
The following persons have my permission to pick up my child:
Name: ____________________________ Phone:_______________________
Relationship: ________________
Name: ___________________________ Phone:_______________________
Relationship______________________
Emergency Medical Authorization
Emergency Medical Contact Information
If neither parent or guardian can be reached in case of an emergency please call:
Name:_______________________________ Phone: ________________________
Relationship: _________________________
Name: ________________________________ Phone: ____________________
Relationship: _____________________
Name of Child’s Doctor: _________________________________________________________
Doctor’s office phone: ____________________________________________________________
Doctor’s office address: __________________________________________________________
Name of Child’s Dentist: _________________________________________________________
Dentist’s office phone: ___________________________________________________________
Dentist’s office address: _________________________________________________________
Your Hospital ofChoice: __________________________________________________________
Insurance Company: ____________________________________________________________
Child’s Insurance Card #: _________________________________________________________
Does your child take any prescription medicine daily? If so, describe reason for treatment:
______________________________________________________________________________________
______________________________________________________________________________________
If I cannot be reached to make arrangements for emergency medical care for my child at the time of an illness, accident, or injury, I give my permission for the owner or staff of Small Meadows Preschool to obtain whatever treatment may be deemed necessary for:
__________________________________________________________________________________________
Full name of Child D.O.B
_________________________________________________________________________________________
Parent/Guardian Signature Date
ALLERGY INFORMATION:
Does your child have any known allergies?
Yes
No
If yes, please list: ______________________________________________________________________
_____________________________________________________________________________________
Does your child’s allergy require anEpiPen?
Yes
No
I agree to promptly notify Small Meadows Nature Preschool of any changes of the above information. This form is legally binding, so by signing it, you agree that all of the information provided herein is correct. False information may result in termination of preschool enrollment, forfeiture of preschool tuition, or both. I agree to be responsible for any and all costs related to transportation or treatment my child receives for medical care.
_______________________________________________
Parent Signature
Date
SMALL MEADOWS TUITION CONTRACT
The following is a legally binding contract between Small Meadows Preschool and
______________________________________________
(Please print parent’s full name)
Preschool is to be provided for:
______________________________________________
(Please print child’s full name & date of birth)
Tuition is 80$ a day for 3yr olds and 70$ a day for 4 to 5 years and older please circle days requested.
Monday Tuesday Wednesday Thursday Friday
* We understand that circumstances and schedules change, but please know we require a 2 week written notice before discontinuation of enrolment, and a two week written notice of an ongoing schedule change for your child.
A late fee of $5 per day will apply after the 5th of the month if payment is not received. Tuition payments & registration fees are non-refundable.
* Payments are made through Venmo and are due the Sunday before the school week starts.
Payments are due regaless of your childs sick day, families vacation and school closings due to weather or other natural disasters. April Vaction and November vacations are paid vacations.
_________________________________________________________________________________________
Parent Signature Date
Small Meadows Preschool Participation Authorization
I, ______________________________________________________________________________________
(Parent’s full name)
Give permission for my child: ______________________________________________________________
(Child’s full name)
To participate in all activities and use all equipment offered at Small Meadows Preschool
I give my permission for my child to play outside in all seasons and in all kinds of weather including rain, sun, snow and any other safe weather.
The following physical limitations and/or restrictions apply to my child:__________________________
_________________________________________________________________________________________
Exposure to nature and the local flora and fauna is an integral part of a healthy childhood and enhances education exponentially. We provide many opportunities to interact with the natural environment in our living classroom at Small Meadows Preschool. As the parent, I understand the possible risks involved in active outdoor play and the possibility of minor and/or major injuries and I accept full legal responsibility for my child’s involvement in such activities.
I understand that climbing, jumping, crawling, swinging, balancing, running, skipping, and other active gross motor & physical ability enhancing skills are allowed and encouraged at this preschool. I understand that my child will have many opportunities for active outdoor play in all kinds of weather at nature preschool. I will not hold Small Meadows Preschool legally responsible for any injuries incurred while participating in these activities. I also understand that occasional bumps, bruises, splinters or skinned elbows or knees are a possibility with children actively playing outdoors on a regular basis.
I understand the risks of active outdoor play in all types of weather and I will make sure my child has the appropriate outerwear and footwear to participate fully.
___________________________________________________________________________________________
Parent Signature & Date
RELEASE AGREEMENT
Small Meadows Preschool aims to provide an active and physically stimulating environment for children. However, injuries can occur, and you as the parent/guardian assume certain risks. This Release Agreement is you as parent/guardian understanding those risks.
I, on behalf of myself, my spouse and each child designated on the Registration Form, waive and release all rights, causes of action and claims against Small Meadows Preschool (and its Owners, Officers, Directors, Staff, Agents and Employees, for any and all loss of or damage to property or injuries suffered by my child during the time my child is in attendance at Small Meadows,including any possible negligence of Small Meadows.
I understand that the provision of our services contains risk of injury to persons and damage to property, and that by signing this Release I engage Small Meadows Preschool to provide care for my child at my own risk. I have been given an opportunity to ask questions and obtain answers to my satisfaction regarding any and all aspects of Small Meadows and the Release, including, but limited to, future risks, complications and costs.
By signing this Release, I have not relied on any promises or statements made by Small Meadows other than those contained in the written information supplied to me by Small Meadows. I understand that this Release will be kept on file and will continue to be in effect for this and any future visits my child may make to Small Meadows.
I HAVE READ THE ABOVE CAREFULLY AND I HAVE A FULL UNDERSTANDING OF THE CONTENT AND CONSEQUENCES OF THIS AGREEMENT BEFORE SIGNING. I FULLY UNDERSTAND AND AGREE TO ABIDE BY THE POLICIES AND GUIDELINES SET FORTH BY: Small Meadows Preschool.
_________________________________________________________________________________________
Parent Signature & Date
PRESCHOOL HEALTH HISTORY FORM
Child’s name __________________________________________________________
Birth Date __________________________________________________________
Parent/Guardian Name _________________________________________________
Family members/siblings _________________________________________________
*This information will help us get to know your child better. It will be kept confidential.
GENERAL DEVELOPMENT
Does your child have any diagnosis or developmental concerns? If so, please describe:
_____________________________________________________________________________________________________________________________________________________
Does your child get along well with other children? ☐ Yes ☐ No
Is he/she usually happy? ☐ Yes ☐ No
When was the last time your child saw a doctor? ___________________________
Does your child take any medications regularly? ___________________________
EXPERIENCE WITH OTHERS
Has your child attended preschool/ Summer camp before? ☐ yes ☐ no
If yes, were there any specific reasons for leaving? _______________________________________________________________________________________________________________________________________
What are some of the ways in which your child plays at home? ___________________________________ __________________________________________________________________________________________
Does he/she play with children from other families? ____________________________________________
Is the entire family together for any time of the day?____________________________________________
EATING HABITS
At what time does the child eat: Breakfast? _____Dinner? ______Supper? ________ Snack?
What is his/her general attitude toward eating?__________________________________________
If she/he refuses to eat, how is this handled and by whom? ________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Favorite foods _______________________________________________________________________
Disliked foods_______________________________________________________________________
Food she is allergic to _________________________________Symptoms _____________________
____________________________________________________________________________________
SLEEP HABITS
Has room alone ____Shares with other children____ Rooms with parents______
At night sleeps from _______to ________ Average hours of nap? _____________
Does the child wet the bed? _______ At nap? _______ At night? _______________
TOILET HABITS
Does he/she tell you when they need to go to the toilet and go willingly? ___________________________________________________________________________________
Can he/she manage clothes at the toilet? ________________________________________________
SPEECH AND PHYSICAL GROWTH
Does she/he communicate well? _____ Fairly well _____ Not very well ____
Any developmental delays or concerns? ___________________________________________________
______________________________________________________________________________________
Does anyone read to him? _____________How Often: __________________
VISION AND HEARING
Does your child wear glasses?
Yes
No
Does your child have difficulty hearing?
Yes
No
Would you describe your child as:
a. active or quiet
b. shy or outgoing?
Any other information we should know about your child? ________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________
*please provide a copy of your child’s immunization records. Your child will be unable to have your child join us without immunization records on file.
* Small Meadows does have a registered nurse available should the need arise, Mellinda Wakefield. Mellinda is also Christina’s mother.