ENROLLED STUDENT Please enable JavaScript in your browser to complete this form. - Step 1 of 3LayoutChild's Name *FirstLastAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhysician's Name *FirstLastPhone *Dentist's Name *FirstLastPhone *Date of Birth *Child's GradePreschool Age 3 by 10/15Pre-K Age 4 by 10/15Kindergarten12345Please check all that apply:AllergiesAsthmaDietary RestrictionsFears or PhobiasIndividualized Educational Plan (IPE)Physical LimitationsSerious injury or surgery in the last yearOther Conditions or ConcernsPlease explain any checked boxes below.Explain Any Checked Items Above Please Check all that apply: InhalerEpiPenMedication (Prescribed or OTC)An Authorization to Dispense Medication Form must be completed for each item checked. Preferred Hospital *NextLayoutParent/ Guardian 1 *FirstLastP/G 1 Primary Phone *P/G 1 Secondary PhoneStreet AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeMailing Address If different from aboveMailing AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *Place of Employment *Parent/Guardian 2FirstLastP/G 2 Primary PhoneP/G 2 Secondary Phone Street AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeMailing Address If different from aboveMailing Address Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail Place of Employment NextAuthorizations and Permissions Names of others authorized to pick-up your child *Names of others NOT authorized to pick-up your child *LayoutProvide emergency medical treatment/transportationAuthorizeDo Not AuthorizeParticipation in and transportation to on/off campus activities and events *AuthorizeDo Not AuthorizeWatch G/PG rated movies *AuthorizeDo Not AuthorizeUse or distribution of images or personal information on any publications, social media, or promotional materials *AuthorizeDo Not AuthorizeApply sunscreen *AuthorizeDo Not AuthorizeParticipate in activities including but not limited to swimming *AuthorizeDo Not AuthorizeEmergency Contact 1 (Other Than Parent/Guardian) *FirstLastPhone *Emergency Contact 2 (Other Than Parent /Guardian)FirstLastPhone *LayoutSignature *Date *Submit
