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To enroll print this form, fill it out, and mail it along with $20.00 to:

Great Beginnings Preschool
2020 South 291 Highway
Independence, Missouri 64057

 

 

                        Great Beginnings Preschool         

 

 

                                                                 2020 South 291 Highway

                                                Independence, Missouri 64057

                                                                461-0266

 

              Enrollment Form (06/07)

       The Great Beginnings Preschool admits students of any race, color and national or ethnic origin.

 

 

                                          Student Information

 

Name                                                                                                                         Birthday                               

 

Home                                                                                                                         Phone                                  

Street                                        City                               Zip

 

Father

 

Name                                                                         

 

Address                                                                      

                 (If different than above)

 

Occupation                                                                 

 

Employer                                                                                 Work Hours ______________________

 

Street                                                                          City                                                                

           

Home Phone ____________                             Cell Phone ___________

 

Mother

 

Name                                                                         

 

Address                                                                      

                 (If different than above)

 

Occupation                                                                 

 

Employer                                                                                 Work Hours ______________________

 

Street                                                                          City                                                                

           

Home Phone ____________                             Cell Phone ____________

 

 

Other Members Of Household                                                                                                                              

(Names & Ages)

 

 

                                            General Information

 

 

                                                        I would like to help in the following areas:

                                                        ·      Sending snacks or fruit juice

                                                        ·      Going on field trips

                                                        ·      Helping with parties

                                                        ·      Chairman of party helpers

 

 

                                                  Field Trips

 

My child has permission to attend the field trips planned by Great Beginnings Preschool.  If there is any exception I will notify the teacher or the director prior to the trip.

 

 

The Following Are Authorized To Pickup My Child

 _______________________________________________________

 

 _______________________________________________________

 

 _______________________________________________________

 

 _______________________________________________________

 

 _______________________________________________________

 

 _______________________________________________________

 

  

The Following Are Not Authorized To Pick Up My Child

 

 

 _____________________________________________________

 

 _____________________________________________________

 

 _____________________________________________________

 

 _____________________________________________________

 

 _____________________________________________________

 

 _____________________________________________________ 

 

 

 

 

 

 

                                                  Emergency

 

 

Person who will care for child in emergency if the parent is not available.

 

 

Relationship      Name                                                                Address                                     Phone

 

_________________________________________________________________________________________________________________________________

 

Relationship      Name                                                                Address                                     Phone

 

_________________________________________________________________________________________________________________________________

 

Family Physician Or Clinic_____________________________________________________________________________________

                                              Name                                                                            Phone

 

_________________________________________________________________________________________________________________________________ 

Street                                                                City                               Zip

 

List any special problems such as speech defects, allergies, or behavior problems.

 _________________________________________________________________________________________________________________________________

 

_________________________________________________________________________________________________________________________________

 

_________________________________________________________________________________________________________________________________

 

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 Please attach your child’s immunization record and medical form provided to you by your child’s physician.

 

 

The school has my permission to call my doctor in an emergency when I or my emergency number can not be reached.  If we can not be reached then they may call another doctor or take my child to the nearest hospital (Medical Center Of Independence) at my expense.

 

 

______________________________________________________________________________________________________________ 

Insurance Company                                                                                                      Policy Number

 

 

 

Waiver Of Liability

 

I understand that the children are supervised at all times and every precaution is taken to prevent accidents.  I relieve the staff of Great Beginnings Preschool and the East Independence Church Of Christ, 2020 S 291 Highway, Independence, Missouri of any liability in the event of an accident or injury while my child is attending any preschool or mother's day out event.

 

 

Parent/Legal Guardian Signature

 

1. I have been informed of the required health and safety inspections and that the inspection forms are available for review.

2. When my child is ill, I understand and agree that my child may not be accepted for care.

 

     Signature                                                                                       Date                                       

 

Please return with $25.00 enrollment fee.