Private day school admission, near Jacksonville Beach, FL, apply today

Student Information

Child's Full Legal Name*

First Last

Child's Preferred Name/Nickname*

Child's Gender*

Applying for which program?*

Number of Days*

Do you require before or after care for your child?

Before Care
After Care

Child's Date of Birth*

Primary residence of child*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone Number*

Who does the child live with?*

Relationship to Child*

Requested start date (dependent on availability)*

Parent / Guardian Information

Primary Contact - Parent / Guardian

Primary Contact - Parent / Guardian Name*

First Last

Primary Contact - Parent / Guardian Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Contact - Parent / Guardian Home Phone*

Primary Contact - Parent / Guardian Cell Phone*

Primary Contact - Parent / Guardian Email*

Primary Contact - Parent / Guardian Employer*

Primary Contact - Parent / Guardian Business Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Primary Contact - Parent / Guardian Business Phone*

Secondary Contact - Parent / Guardian

Secondary Contact - Parent / Guardian Name*

First Last

Secondary Contact - Parent / Guardian Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Secondary Contact - Parent / Guardian Home Phone*

Secondary Contact - Parent / Guardian Cell Phone*

Secondary Contact - Parent / Guardian Email*

Secondary Contact - Parent / Guardian Employer*

Secondary Contact - Parent / Guardian Business Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Secondary Contact - Parent / Guardian 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.

Emergency Contact*

First Last

Authorized Person #1 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.

Medical Information

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

Languages spoken at home

Is your child toilet trained? (Required for ages 3 through Elementary)*

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:*

Does your child attend any sort of therapy? If yes, please describe:*

Does your child require an emergency care plan?*

Yes
No

Enrollment Consent*

I understand enrollment and re-enrollment fees are non-refundable.

Name

This field is for validation purposes and should be left unchanged.

Apply Today

Apply today to begin the admission application process to Collage Day School

For new student enrollment, a school tour is required before filling out this form.

Please complete the registration form before.

Student Information

Parent / Guardian Information

Primary Contact - Parent / Guardian

Secondary Contact - Parent / Guardian

Additional Persons Authorized to Pick Your Child Up & Emergency Contacts

Medical Information

Student Profile / Background Information

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