Hybrid Montessori admission Form - Creative Labs Center

Enrollment Form

6180 Atlanta Hwy, Alpharetta, GA 30004

A. Child Information

Name

M/F

Date

Name

M/F

Date

Name

M/F

Date

Home Address

Home Phone

Living Arrangements:

Mother

Father

Both

Other

Legal Guardians:

Mother

Father

Both

Other

B. Parent/Guardian’s Information

Mother’s or Guardian’s Name

Cell Provider

Cell

Employer

Occupation

Employer’s Address

Work Ph.

E-Mail

Father’s or Guardian’s Name

Cell Provider

Cell

Employer

Occupation

Employer’s Address

Work Ph.

E-Mail

C. Special Alert

The following IS NOT allowed to pick up my child. A court order is required on file at the center in order to uphold special custody situations.

Name

Relationship to Child

Comments

D. Health Information

Please fill in child’s name and write NONE if your child has no known medical conditions. List past and current medical conditions or ongoing medications.

Child’s Name

Allergies

Child’s Name

Allergies

Child’s Name

Allergies

Doctor’s Name / Clinic

Phone

E. Medical Authorization

In the event that my child is injured or becomes ill while at Creative Labs, I hereby grant Creative Labs to take whatever necessary actions in supplying emergency medical treatment. This includes calling 911 to transport my child to an emergency medical facility. I understand that I am responsible for payment of such services. I also understand that Creative Labs will make every attempt to contact me or my designated emergency contacts and follow the instructions given. In the event that Creative Labs is unable to contact me or my emergency contacts, I hereby grant permission to Creative Labs to comply with the instructions given by the attending physician, ambulance personnel, or emergency facility personnel.

Parent’s Signature

Date

F. Emergency Contact Information (Other than Parent/Guardian)

Person whom you authorize Creative Labs to contact in the event of an emergency, in which the parent/guardian is unavailable, and whom you authorize the child to be released to.

Emergency Contacts MUST be Local and Readily Available

Name 1

Relationship to Child

Address

Home

Work

Cell

Relationship to Parent/Guardian

Name 2

Relationship to Child

Address

Home

Work

Cell

Relationship to Parent/Guardian

G. Photograph/ Video Release

Person whom you authorize Creative Labs to contact in the event of an emergency, in which the parent/guardian is unavailable, and whom you authorize the child to be released to.

I hereby grant permission to Creative Labs to video or photograph my child

The pictures or video will be shared with other parents to show the children engaged in their daily activities. Pictures or video may also be used for Creative Labs website, Facebook, or print advertising. The undersigned hereby jointly and severally releases, acquits, forgives, and discharges Creative Labs, from any actions, agreements, claims, controversies, demands, judgments, liabilities, proceedings, and suits, whether arising in equity or in law regarding such participation and appearance by my child.

Parent’s or Guardian’s Signature

Date

H. Parent Agreement

1) I will provide updates to my child’s records and inform the staff immediately. 2) I will ensure that parents or emergency contacts will always be readily available for emergencies. 3) Parents will be informed of any incidents, illnesses, injuries and adverse reactions to medication. 4) Creative Labs will inform and discuss with parents matters relating to their child’s well-being and development. 5) My child will only be transported for field trips with written permission. I hereby acknowledge that I have read and hereby agree to abide by the Creative Labs Parent Policies and Procedures posted on our website. Any non-compliance of our Policy and Procedures will result in dis-enrollment.

I. Name of Program Selected:

J. Calendar Type: Daycare / School

Time Slot

Parent’s Signature

Date

Center Administrator’s Signature

Date