Date Registered  _____________

TINY TOT PRESCHOOL AND KINDERGARTEN

 Starting Date   ______________
 

  REGISTRATION FORM

 Days  _____________________
  Hours  ____________________
  Discharged  ________________
Child's Name ________________________________________________________________                                            Nickname __________________
  Birthdate ___________________________________________________________ Birthplace  _________________
  Address  ___________________________________________________________ Phone _____________________
  City  ______________________________________________________________ State  ___________  Zip  _____
  Parents:     Single          Married          Widowed          Separated          Divorced
  Mother  _________________________________________________________________________ Phone  ____________________
  Address  ________________________________________________________________________ Work Hours  _______________
  City  ___________________________________________________________________________ Cell/Pager  _________________
  Place of Employment  _____________________________________________________________ Phone  ____________________
  Father  _________________________________________________________________________ Phone  ____________________
  Address  ________________________________________________________________________ Work Hours  _______________
  City  ___________________________________________________________________________ Cell/Pager  _________________
  Place of Employment  _____________________________________________________________ Phone  ____________________
Legal guardian if other than parents:
  Name  _______________________  Address  __________________________________________ Phone  ____________________
If neither Mother or Father can be reached in case of emergency call:
  Name  __________________________________________________________________________ Phone  ____________________
SOCIAL INFORMATION:
  Previous Play Experience:  Yes  _________    No  _________                     Please describe:  
  ____________________________________________________________________________________________________________________
  Other children in family:  Name and age  ___________________________________________________________________________________
  ____________________________________________________________________________________________________________________
  Any physical, emotional or family situations of which the school be made aware of:  ________________________________________________
  ____________________________________________________________________________________________________________________
MEDICAL AUTHORIZATION AND GENERAL PERMISSION
  Child's: Doctor  _______________________________ Address  ___________________________________ Phone  ___________
            Dentist  ______________________________ Address  ___________________________________ Phone  ___________
If emergency medical care is necessary, I give you my permission to remove the above minor from the premises for the purpose of
obtaining medical treatment by a qualified and licensed physician, dentist and or accredited hospital.
CONSENT:  Child Pick-Up-ONLY people you designate in writing ar allowed to remove children from Tiny Tot.
  I authorize  __________________________________________________________________________________________________________
                      Name Address Phone Relationship
  or  _________________________________________________________________________________________________________________
                     Name Address Phone Relationship
  to pick up my child when I am unavailable.
I hereby grant permission for my child to participate in all your activities including walking trips, special excursions and park visits.  I also grant permission
to use photographs of my child for publication or publicity purposes. I hereby release, indemnify and hold you and your agents and employees harmless from
any and all claims, images or other liabilities for injuries to or damage by my child which are not the result of gross negligence by Tiny Tot Preschool and
Kindergarten, it's agents or employees. I hereby warrant to Tiny Tot Preschool and Kindergarten that I am entitled to legal custody and possession of my
child, and accordingly am authorized to place my child in your care, and am further authorized to sign this enrollment form.
  ________________________________________________
 

Parent or Guardian's Signature
Date ___________________________________ ________________________________________________
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