Choose a Location and Class *

Student's First Name: *

Student's Last Name: *

Student's written name at Kindergarten: (ex. Johnathan "Johnny") *

Birthdate: *

Gender: *

Mother's Name: *

Mother's Email: *

Mother's Cell Phone #: *

Mother's Phone # can be added to the Remind Texting App for school reminders, information and emergencies: *

Mother's Address: *

Father's Name: *

Father's email: *

Father's Cell Phone #: *

Father's Cell Phone # can be added to the Remind Texting App for school reminders, information and emergencies: *

Other Guardian Name: (if applicable)

Other Guardian Email: (if applicable)

Other Guardian Cell Phone #: (if applicable)

Other Guardian's Cell Phone # can be added to the Remind Texting App for school reminders, information and emergencies:

Other Guardian Address: (if applicable)

Living Situation: Student resides with? (Check all that apply) *

Number of Siblings? *

Names and Ages of Siblings:

Personality Information: Please give a brief explanation of our child's personality: (happy, shy, outgoing, timid, aggressive etc...) *

Does your child have any allergies: *

Allergies: If yes, please explain:

Does your child have any needs we should be aware of? (medical, social, behavioral, speech etc... ) *

Needs: If yes, please explain:

Current on Immunizations? *

Pediatrician Office and Phone # *

Emergency Treatment Release: I hereby give my consent to Puddle Jumper staff to administer first aid or to call for emergency medical help. I further consent to medical procedures to be performed for my child by a licensed physician or hospital if deemed necessary to safeguard my child's health. Any expense incurred will be accepted by me. Please Digitally Sign and Date: *

Emergency Contacts: (Other than persons listed above) Only designated persons will be allowed to pick up your student. ID may be required (Please list name, phone number and relation to the student for each additional emergency contact)

Carpooling: (riding home with other students at Puddle Jumper)

Carpooling: If yes, please list names and phone #'s of carpool group.