2017-2018 Enrollment Form.ods
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2017-2018 Enrollment Humpty Dumpty Preschool
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Tues/Thurs
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Mon – Fri
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Mon/Wed/Fri
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Child's Full Name
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AddressCityStateZipBirthdateGender
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Please list any Allergies, special medical conditions , or fears your child has. Please include any other concerns or information you would like the teachers to know. Special medications and/or restrictions:
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Because parent helpers vary from day to day, if your child has a medical condition or food allergy, Humpty requires the person bringing your child to Humpty to discuss with, each school day, the parent helpers and the teacher about the day's snacks, beverages, or if applicable - cooking/food activities. It is the parent's responsibility to daily make the parent helpers and teacher aware of their child's food allergies and/or medical condition. No medication may be administered by the teacher or by the parent helpers.
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Mother's NameEmail AddressHome Phone
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AddressCityStateZipCell Phone
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Social Security NumberEmployerHours of Employment
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AddressCityStateZipWork Phone
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Father's NameEmail AddressHome Phone
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AddressCityStateZipCell Phone
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Social Security NumberEmployerHours of Employment
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AddressCityStateZipWork Phone
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Emergency Contacts (Other Than Parents or Doctor) ALL INFO REQUIRED
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Contact 1Phone 1Phone 2
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Address
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Contact 2Phone 1Phone 2
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Address
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Person(s) Authorized to Take Child From Humpty Dumpty (Other Than Parents)
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NameNameName
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NameNameName
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Field Trip and Transportation
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_____I DO NOT_____I DOGive consent for my child to take part in field trips or excursions with Humpty Dumpty under proper supervision in private transportation. Therefore, Humpty Dumpty does not assume responsibility for damages and/or injuries during field trip transportation. Drivers of private vehicles assume responsibilities of accidents and/or injuries that may occur during field trip transportation. It is my understanding that I will be notified when such trips are planned.
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Vehicle Information
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All parents could possibly be field trip drivers over the course of the school year. PLEASE ATTACH A COPY OF YOUR AUTO INSURANCE CARD(S). Please remember to submit a copy of your insurance card upon renewal.
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YearMakeModelNumber of seats available for use by the children. Do not include seats with airbags.
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YearMakeModelNumber of seats available for use by the children. Do not include seats with airbags.
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Agreements
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A. When my child is ill, I understand and agree that my child may not be accepted for care.
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B. I do have current auto insurance and will maintain it throughout the time my child is enrolled at Humpty.
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C. My child is, to my knowledge, in good health and free of disabilities that would endanger him/her or other children at Humpty Dumpty.
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SignatureDate
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Authorization for Emergency Medical Care
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I understand that in case of an accident or injury to my child, I will be notified immediately. If my child requires emergency medical care, the physician and preferred hospital to be used are as follows.
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Doctor/Clinic NamePhone
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Preferred Hospital NamePhone
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Insurance Company24 Hour Phone Number
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Insurance Policy NumberCard Expiration Date
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In case of injury in my absence, I the parent or guardian of the above named child hereby consent to any and all medical and surgical treatments and procedures, including anesthetics, which may be deemed necessary by the above named physician or by the professional staff of Boone Hospital, Regional Hospital, or the University of Missouri-Columbia Hospital. Please sign in the presence of a Notary Public (many banks provide this service free to their customers). PLEASE ATTACH A COPY OF THE FRONT AND BACK OF YOUR CHILD'S HEALTH INSURANCE CARD.
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Signature in the presence of Notary PublicDate
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Notary Public's SignatureDate
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Notary SealMy Commission Expires
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Humpty Dumpty Christian Co-op Preschool admits students of any race, color, and national or ethnic origin.
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For office use only
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Admit DateDischarge DateEnrollment Fee Paid? No / Yes Date paid__________ Check #__________
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