Ultimate School-Agers Nursery School Enrolment Form

Last Name______________________________________________________________

First and Middle Name ____________________________________________________

Preferred Name __________________________________________________________

Address ________________________________________________________________

Phone Number ___________________________________________________________

Does your child have any allergies? __________________________________________

If yes, please state what he/she is allergic to ____________________________________

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Does your child have any other health concerns we should be aware of? ______________

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What kind of activities does your child like to do? _______________________________

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What kind of activities does your child not like to do? ____________________________

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Is there anything else you would like us to know about your child? __________________

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Emergency Contact Information:

Contact Number Priority 1: Name ____________________________________________

Home Phone Number ________________ Work Phone Number ___________________

Cell Phone Number _______________________________________________________

Relationship to Child ______________________________________________________

Contact Number Priority 2: Name ____________________________________________

Home Phone Number _________________ Work Phone Number __________________

Cell Phone Number ______________________________________________________

Relationship to Child ______________________________________________________

Contact Priority Number 3: Name ____________________________________________

Home Phone Number ______________________Work Phone Number ______________

Cell Phone Number _______________________________________________________

Relationship to Child ______________________________________________________

Contact Priority Number 4: Name ____________________________________________

Home Phone Number ______________________Work Phone Number ______________

Cell Phone Number _______________________________________________________

Relationship to Child ______________________________________________________

Is there a custody order regarding your child? ________________________________

Is there someone who does not have permission to pick your child up under any circumstances? ________________________________________________________

Does Ultimate School-Agers have your permission to take pictures of your child? ___________________________________________________________________

Would you be interested in receiving communication through e-mail for our monthly newsletters and upcoming events? ____________________________________________

If so, please state your e-mail address _________________________________________

Your e-mail will be blocked from others and you will only receive information regarding your child’s program.

Comments ______________________________________________________________

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Signed ____________________________________ Dated ________________________