Fillable APPLICATION FOR ADMISSION

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APPLICATION FOR ADMISSION

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APPLICATION FOR ADMISSION
REGISTRATION DEADLINE: DECEMBER 18
TH
, 2020
Copyright © 2014 Raintree School, all rights reserved.
1
ATTENDANCE INFORMATION ANTICIPATED DATE OF ENTRANCE: _________
2021-22 School Year: Full Day Part Time Half Day Kindergarten Not Attending
SUMMER 2021 Session 1: Attending Not Attending Session 2: Attending Not Attending
GENERAL STUDENT INFORMATION Our personal information has changed.
First Name: _________________ Middle Name: _________________ Last Name: _________________
Home Address: ________________________
City, State Zip: ________________________
Home Phone: (____) ____ - _______
Home Fax: (____) ____ - _______
Sex: M F
Birthday: ___________
Previous School Attended: _______________________ Primary Language: _________________
Does your child need help:
Dressing? Y N
Eating? Y N
Washing hands? Y N
Is your child potty-trained? Y N
Does your child have any phobias? Please explain:
______________________________________________________
______________________________________________________
FIRST PARENT/GUARDIAN INFORMATION
First Name: _________________ MI: ___ Last Name: _________________ Birthday: ___________
Address and Phone Numbers Same as Child
Home Address: _______________________
City, State Zip: _______________________
Home Phone: (____) ____ - _______
Cell Phone: (____) ____ - _______
Home Fax: (____) ____ - _______
Title: Mr. Mrs.
Ms. Dr.
Employer: _______________________
Work Address: _______________________
City, State Zip: _______________________
E-mail: _______________________
Work Phone: (____) ____ - _______
Work Fax: (____) ____ - _______
Relationship to Child
_________________
Hours of Employment
_______ to _______
Parents’ Marital Status: Married Divorced
Single Widowed
SECOND PARENT/GUARDIAN INFORMATION
First Name: _________________ MI: ___ Last Name: _________________ Birthday: ___________
Address and Phone Numbers Same as Child
Home Address: _______________________
City, State Zip: _______________________
Home Phone: (____) ____ - _______
Cell Phone: (____) ____ - _______
Home Fax: (____) ____ - _______
Title: Mr. Mrs.
Ms. Dr.
Employer: _______________________
Work Address: _______________________
City, State Zip: _______________________
E-mail: _______________________
Work Phone: (____) ____ - _______
Work Fax: (____) ____ - _______
Relationship to Child
_________________
Hours of Employment
_______ to _______
EMERGENCY CONTACTS / PICKUP AUTHORIZATION
First Name: _________________ Last Name: _________________
Relationship to Child: _________________
Home Phone: (____) ____ - _______
Cell Phone: (____) ____ - _______
First Name: _________________ Last Name: _________________
Relationship to Child: _________________
Home Phone: (____) ____ - _______
Cell Phone: (____) ____ - _______
APPLICATION FOR ADMISSION
REGISTRATION DEADLINE: DECEMBER 18
TH
, 2020
Copyright © 2014 Raintree School, all rights reserved.
2
STUDENT MEDICAL INFORMATION
Allergies:
__________________________________________________
__________________________________________________
Dietary Restrictions:
__________________________________________________
__________________________________________________
Chronic Health Conditions:
__________________________________________________
__________________________________________________
Special Limitations and Concerns:
__________________________________________________
__________________________________________________
Physician/Clinic: ______________________________
Address: ______________________________
City, State Zip: ______________________________
Phone: (____) ____ - _______
Fax: (____) ____ - _______
Has your child ever received special education?
Dates of Service
Resource ________ to ________
Speech Therapy ________ to ________
Structured Behavior ________ to ________
Related Service (i.e. OT, PT) ________ to ________
Inclusion Class ________ to ________
Other Health Impaired ________ to ________
Please specify ____________________________________
Preferred Hospital for Emergency Care: _________________
Address: ________________ Phone:
City, State Zip: ________________ (____) ____ - _______
PERMISSIONS
I do do not give consent for my child to take part in field trips or excursions with Raintree School under proper
supervision. I understand I will be notified when such trips are planned and that I must give written permission for each field trip
or excursion.
I do do not give consent for photographs of my child to be taken at the Raintree School campus to be used solely for
educational and/or promotional purposes. I understand that photographs of my child will never be sold to any third party and
that my child’s name will never be tied to his/her photograph except in material intended solely for internal Raintree School use.
I do do not give Raintree School permission to administer basic first aid and/or CPR to my child and/or take my child to
a hospital for medical treatment when I cannot be reached or when delay would be dangerous to my child’s health. I understand
that I will be notified at once in case of accident or illness to my child, and I will make arrangements for medical care of my child
with the physician or hospital of choice.
AGREEMENTS
a) Raintree School and I have agreed on a plan for communication regarding my child’s development, behavior, etc.
b) When my child is ill, it is understood and agreed that he/she may not be accepted for care.
c) I have received a copy of Raintree School’s policies pertaining to the admission, care and discharge of children.
d) I have been informed that the Licensing Rules for Child Care Centers in Missouri are available at this office for review.
e) Raintree’s deposit policy has been explained to me, and I fully understand and agree to abide by the policy.
PARENT/LEGAL GUARDIAN SIGNATURE: _______________________________ Date: ____________
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APPLICATION FOR ADMISSION

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Completed 4 April 2022

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