Fillable Kindergarten Readiness App 2016 Fillable REGISTRATION FORM Sample

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Kindergarten Readiness App 2016 Fillable REGISTRATION FORM Sample

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The Kindergarten Readiness App 2016 Fillable REGISTRATION FORM Sample form is 3 pages long and contains:

  • 4 signatures
  • 1 check-box
  • 60 other fields

Country of origin: US
File type: PDF

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Kindergarten Readiness Program
College of Education
PARTICIPANT INFORMATION
Last Name: First Name: ___________
Gender:
Female
Male Age: _
School attending for Kindergarten:
Home address:
City: State/Province: Postal/Zip Code:
Country: Telephone: Cell:
Please list ADA Accommodations needed:
Parent/Guardian: _____________Day phone:__________Cell Phone:
____________
Parent/Guardian: _____________Day phone:__________Cell Phone:
____________
Parent/Guardian email:__________________________________________________________
This is a half-day program (8:00am-12:00pm). Pick-up is at 12:00 noon in Billy C. Black Building
Room 183. There is a fee for late pick-up. Extended Day Services are offered through the Early
Learning Center (ELC). Those participants enrolled in Extended Day Services will be dropped off
at the ELC AT 12:00pm. Parents MUST enroll in Extended Day Services directly with the Early
Learning Center.
Please sign where appropriate:
Half-Day Program (pick-up at 12:00): ___________________________
Extended Day Services (drop-off to ELC): ________________________
Emergency contact*: Relationship: Phone:
Specify any of your child’s health problems:
Is your child on any medication? No Yes If so, please specify:
Lunch: Lunch is provided. If you prefer to send your child’s lunch, please be sure that your child’s belongings
are clearly marked with your child’s first name and last name. Children can also bring their own snacks. Do
not include peanuts or peanut-based products. Refrigerators will not be available for your child to store
his/her lunch. Glass bottles/containers are also not allowed.
Location: All children will report to Billy C. Black Bldg. for academic instruction from 8:00-12:00pm. Children
participating in the extended day program will be transported to the Early Learning Center at 12:00pm.
Contact Information
For more information, contact Dr. Erica DeCuir, Director of the Summer Learning Academy at:
229-430-4717 Email: erica.decuir@asurams.edu
.
SIGNATURE OF PARENT OR GUARDIAN DATE
REQUIRES PARENT’S SIGNATURE:
You have our permission, in the event of an emergency and in case we are unavailable, to authorize any
physician, nurse practitioner or medical personnel to examine, interview, test and if necessary, treat my
child_______________________________________________ as they may deem advisable.
Parent/Legal guardian name________________________________________________Date_______________
Parent/Legal guardian Signature_____________________________________________Date_______________
Student Allergies________________________________________________________________
Student Medical Problems_______________________________________________________________
Doctor______________________________Phone number____________________________________
Insurance carrier______________________Policy number______________________________________
Effective Date of Coverage:______________________
Will child be required to take medication during camp hours? Yes or No
Does child use an inhaler? Yes or No
Is child under the care of a physician? Yes or No
Is child restricted from physical activity? Yes or No
Does child have any known food allergies? Yes or No
Parent/Legal guardian signature _______________________________ Date__________________
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Pick-Up Authorization Form (For those NOT participating in Extended Day)
Child’s Name ____________________________________________________________________________
Parent/Guardian: _________________________________________________________________________
List Name of Person(s) Dropping Minor Off
I will be picking up the minor child each day at approximately ____
12:00________ pm.
The minor listed above may be released to any of the following:
_________________________________________________________________________________________
Name Contact Number(s)
_________________________________________________________________________________________
Name Contact Number(s)
_________________________________________________________________________________________
Name Contact Number(s)
By my signature below, I understand:
(1) that my child will NOT be released to anyone other than the person(s) listed on this form;
(2) that I will be assessed a late pick-up fee of $10.00 if the child is not picked up by 12:00pm and that
the late fee must be paid before my child is allowed to return on the following day.
__________________________________________
Parent/Guardian Signature
__________________________________________
Date
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Kindergarten Readiness App 2016 Fillable REGISTRATION FORM Sample

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Completed 21 February 2020

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