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Family Enrollment Form
After you fill out this enrollment form, we will contact you to go over details and answer any last minute questions you might have before the first day of care. If you need an immediate response or help with the enrollment process please contact us at (585) 210-8554 or our director at rosamarie@marvelousmindacademy.com
Are you enrolling a new or returning student? *
Which service/program are you enrolling in? *
Choose a start date
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Child's Full Name *
Your answer
Date Of Birth *
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Address *
Your answer
Contact Information
Your Name *
Your answer
Phone Number *
Your answer
E-mail *
Your answer
Preferred contact method *
Address
If different from above
Your answer
Job Title
Your answer
Employer *
Your answer
Employer Address
Your answer
Work Phone
Your answer
Guardian 2
Name
Your answer
Phone Number
Your answer
E-mail
Your answer
Preferred contact method
Address
If different from student's
Your answer
Job Title
Your answer
Employer
Your answer
Employer Address
Your answer
Work Phone
Your answer
Health History Form
The child’s guardian must complete the following information. The intent of this information is to gather the child’s health background so we may provide the appropriate health care treatment. Please provide complete information so that we can be aware of any child’s special needs. Any changes to this form should be provided to us in writing. The information on this form is not a part of the child acceptance process but is gathered to assist us in identifying appropriate care. Keep a copy of this completed form for your records.
Physician's Name
Your answer
Phone Number
Your answer
Address
Your answer
Does your child have any medical conditions that should be considered?
Your answer
Are there any special instructions as to treatment from you or your child's doctor?
Your answer
Routine Medications
Please list all medications, including non-prescription, taken routinely. Marvelous Mind Academy prefers that all medications be administered at home whenever possible. However, if lunch time medications are required, please send enough medication to last the entire week. Keep it in the original packaging that identifies the prescribing physician (if it’s a prescription drug), the name of the medication, the dosage, and the frequency of administration. A Marvelous Mind Academy Medical Consent Form must be completed in order for medication to be administered.
Your answer
Allergy Information
Please list any allergies below. Also provide reaction and management of the reaction.
Your answer
Important! This section must be completed for attendance.
Guardian Authorization *
Required
Permission to provide necessary treatment or emergency care *
Required
As the parent or guardian of the child whose name appears above:
I approve this registration and give my permission for the child to participate in all planned activities (except as may be noted on this registration). *
Required
In consideration of the child named above being allowed to participate in the activities of Marvelous Mind Academy and to use its facilities (whether owned or leased), equipment and machinery, I do hereby waive, release and forever discharge Marvelous Mind Academy and its officers, agents, employees, volunteers, representatives, directors and all others from any and all responsibility or liability for injuries or damages resulting from the child’s participation in such activities (including transportation to and from the center and including off-site trips) or use of such facilities, equipment or machinery, unless such damage or injury results from a negligent act or omission. *
Required
I agree that Marvelous Mind Academy may photograph or videotape the child, and Marvelous Mind Academy may use those photographs or video footage for its marketing purposes. I release Marvelous Mind Academy from any claim or liability related to that use, and waive all claims against the individual staff persons and Marvelous Mind Academy. *
Required
I understand Marvelous Mind Academy is not responsible for lost, stolen or damaged personal articles. *
Required
Today's Date *
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Need to enroll another child? *
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