Apply Today - Collage Day School

Student Information
Child's Name*
First Last
Child's Preferred Name/Nickname*
Child's Gender*
Applying for Which age group?*
Number of Days*
Do you require before or after care for your child?
Before Care
After Care
Child's Date of Birth*

Child's Age as of September 1, 2019 (years/months)*
Primary residence of child*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone Number*
Parent's are:
Married
Divorced
Father Deceased
Mother Deceased
Single Parent
Child is Adopted
Who does the child live with?*
Relationship to Child*
Parent / Guardian Information
Parent / Guardian #1
Parent / Guardian #1 Name*
First Last
Parent / Guardian #1 Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent / Guardian #1 Home Phone*
Parent / Guardian #1 Cell Phone*
Parent / Guardian #1 Email*

Parent / Guardian #1 Employer*
Parent / Guardian #1 Business Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Parent / Guardian #1 Position*
Parent / Guardian #1 Business Phone*
Parent / Guardian #2
Parent / Guardian #2 Name*
First Last
Parent / Guardian #2 Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent / Guardian #2 Home Phone*
Parent / Guardian #2 Cell Phone*
Parent / Guardian #2 Email*

Parent / Guardian #2 Employer*
Parent / Guardian #2 Business Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Parent / Guardian #2 Position*
Parent / Guardian #2 Business Phone*
Are there circumstances about the custody of your child that we should know about, which limit the sharing of records, picking up of your child, etc.?*
Yes
No
It is the parent's / guardian's responsibility to keep the school informed of changes in custody by providing the office with current and complete legal documents each year and after any changes

Additional Persons Authorized to Pick Your Child Up & Emergency Contacts

Important: Child will be released only to the parent or legal guardian, and persons listed below. The following people will also be contacted and are authorized to remove your child from the facility in case of illness, accident or emergency if the parent or legal guardian cannot be reached. Please introduce us to the persons authorized to pick up your child. For the safety of your child, please notify teachers (verbally or in writing) of who will be picking up your child. We will request a photo ID from someone listed below whom we have not previously met before releasing your child to them.
Authorized Person #1 Name*
First Last
Authorized Person #1 Relationship*
Authorized Person #1 Phone Number*
Authorized Person #2 Name*
First Last
Authorized Person #2 Relationship*
Authorized Person #2 Phone Number*
Authorized Person #3 Name*
First Last
Authorized Person #3 Relationship*
Authorized Person #3 Phone Number*
4 Digit Authorization Code*
Please make a 4 digit code that will be used for pick up purposes only. This is a number that you make up and give to people authorized to pick up your child.

AS PARENT / GUARDIAN OF THE ABOVE, I VERIFY THAT THE INFORMATION ON THIS FORM IS CURRENT, THAT I WILL IMMEDIATELY INFORM THE SCHOOL OF ANY CHANGES IN THIS INFORMATION AND I WILL BE RESPONSIBLE FOR TUITION, FINES, OR PENALTIES, ATTORNEY'S FEES AND COURT COSTS RESULTING FROM A FALSIFIED DOCUMENT. I AUTHORIZE THE SCHOOL PERSONNEL TO TAKE RESPONSIBLE EMERGENCY MEASURES, INCLUDING CALLING 911, ON BEHALF OF MY CHILD AND AGREE TO HOLD THEM HARMLESS FOR ANY TREATMENT RENDERED.
Name or Parent / Legal Guardian*
First Last
Signature of Parent / Legal Guardian*
Date*

Medical Information
Child's Full Legal Name*
First Middle Last
Child's Date of Birth*

Child's Physician*
Physician's Phone Number*
Child's Dentist*
First Last
Dentist's Phone Number*
Please list any allergies, medical conditions, developmental delays or medications currently being taken, including dietary requirements, allergies to medication , or any other limitations*
I hereby give permission in the event of an emergency for the Direction, the Acting Director, or a Teacher at Collage Day School, to take whatever steps may be necessary for the medical care of my child. I understand that in or order for Collage Day School to assume responsibility of my child , I, or the person(s) whom I have designated to drop off and pick up my child, must sign my child in at the time of arrival and out at the time of departure. I understand that unless there is a need for immediate action, the order of the steps taken will follow, but will not be limited to, the outline as follows:

The parent / guardian will be called. Note: If the the parent / guardian is unavailable, the emergency contact persons designated by the parent / guardian will be called.

Child's physician will be called.

If these efforts are unsuccessful, the following steps will be taken (order may vary depending on the situation):

Another physician will be called.

The child will be taken to the nearest emergency room accompanied by a staff member.

An ambulance will be called to take the child to the nearest emergency room accompanied by a staff member.

If I cannot be reached in the event of an emergency, I give consent for a Collage Day School staff member to transport my child to the nearest emergency facility, or to have my child transported by ambulance. I give consent to any emergency facility or physician to administer any necessary medical treatment to my child as the situation my warrant it. I further understand that I am responsible for any and all costs associated with and and all medical treatments for my child. Parent / Guardian confirms that they will hold Collage Day School and its staff harmless from any liability which might arise from this consent. Parent / Guardian agrees to reimburse Collage Day School for any medical expenses that may arise while child is in our care.
Name of Parent / Legal Guardian*
First Last
Signature of Parent / Legal Guardian*
Date*

Student Profile / Background Information
Child born Prematurely?*
Yes
No
How many months early?*
Child's Place of Birth*
Languages spoken at home
List child's siblings and their ages*
Please list any other members of your household (pets too!) by name, age and relationship*
If child is adopted, list age at time of adoption*
Is child aware of adoption?*
Is your child toilet trained?*
If in progress, please explain:*
Describe assistance needed and words used:*
Does your child nap?*
Yes
No
What time does your child nap?*
Will your child be able to rest quietly with books for at least a half hour each afternoon?*
Does your child take a bottle at nap time?*
Yes
No
Does your child take a pacifier at nap time?*
Yes
No
What time does your child wake up and go to bed?*
Has your child previously attended preschool?*
Yes
No
Where has your child attended preschool?*
Please describe any health issues that we should be aware of:*
Please describe any special dietary needs that we should be aware of and describe your child's appetite:*
What methods of behavior management are used in your home?*
Does your child attend any sort of therapy? If yes, please describe:*
Describe any serious operation or accident your child may have had:*
List all medications your child takes on a regular basis and the associated conditions*
Please describe any special medical, physical or emotional needs that the school and staff should be aware of:*
What are your child's favorite activities?*
What does your child enjoy doing with Mother?*
What does your child enjoy doing with Father?*
Does your child play well alone?*
Does your child play well in groups?*
Do you think your child will display anxiety on his/her first day of school*
As a parent, what do you feel you can do to avoid an unpleasant first day at school?*
Email
This field is for validation purposes and should be left unchanged.