MILESTONE LEARNING PRESCHOOL

Where Focusing on Achievement Begins

REGISTRATION FORM

Todays Date:___________________________
Date of Admission:__________________________ Date of Withdrawal:__________________
Hours and Days child will be in care:________________________________________________
The following meals will be served to my child when in care:
_____Breakfast _____A.M. Snack _____Lunch _____P.M. Snack
CHILD INFORMATION
Childs Name Date of Birth Age

Childs Address Childs Home Telephone Number

City State Zip Code

PARENT/GUARDIAN INFORMATION
Lives with:

_____Mother _____Father _____Both Parents _____Guardian

_____Other (Specify): __________________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Mothers Name: SS#:

Employer Work# Cell#

Fathers Name: SS#:

Employer Work# Cell#

Address (if different from childs Address)

I hereby authorize the childcare operation to allow my child to leave the childcare
operation with the following persons. Please list names/address/phone number and
relationship to child for each. Children will only be released to a parent or a person
designated by the parent/guardian after verification of Identification.
Name Telephone# Relationship to child

Address City/State Zip Code

Name Telephone# Relationship to child

Address City/State Zip Code

Name Telephone# Relationship to child

Address City/State Zip Code

Name Telephone# Relationship to child

Address City/State Zip Code

Family Security Code:

________________________________________________
EMERGENCY INFORMATION ________________________
Parent/Legal Guardian Signature Date
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Person to be contacted for emergencies in the event that both parents cannot be reached.
Name Telephone# Relationship to child

Address City/State Zip Code

In the event that I cannot be reached to make arrangements for emergency medical attention, I
authorize the facilitys director or person in charge to take my child to:

Name of Licensed Physician Telephone#

Hospital Address

I give my consent for necessary emergency treatment when my child is in the care with this physician
at this clinic and/or hospital.

________________________________________________ ________________________
Parent/Legal Guardian Signature Date

List any special problems that your child may have, such as allergies, existing illnesses, previous
serious illnesses, injuries during the past twelve (12) months, any medication prescribed for long term
Continuous use, and any other information that staff should be aware of:

Explain: ______________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

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 HEALTH REQUIREMENTS
One of the following must be presented when your pre-school age child is admitted to the
preschool facility. Check to indicate the option you select.

DOCTORS STATEMENT: I have examined the above-named child within the past year
and find that he/she is physically able to take part in the preschool program.

Physicians Signature: __________________________________ Date: ____________________

A copy of the MEDICAL SCREENING from the Early and Periodic Screening, Diagnosis
and Treatment (EPSDT) Program if not a referral for further diagnosis and treatment is indicated.

A form or WRITTEN STATMENT from health service or clinic.

NOTE: If medical diagnosis and treatment and/or immunization and TB Testing conflict with
your religious beliefs, you must sign an affidavit to that effect and attach it to this form. If
immunization and/or TB Testing would be injurious to your child or family, you must obtain a
certificate (signed by a physician) to that effect and attach it to this form.

VISION: R 20/_____ L 20/_____ Pass________ Fail________

HEARING: 1000 HZ 2000 HZ 4000 HZ Pass________ Fail________

R _______ ________ ________

L _______ ________ ________

________________________________________________ ________________________
Parent/Legal Guardian Signature Date

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TRANSPORTATION: I hereby GIVE DO NOT GIVE my consent for my child to be
transported and supervised by facilitys staff:

On Field Trips To & From Home To & From School For Emergency Care
FIELD TRIPS: I hereby GIVE DO NOT GIVE my consent for my child to
participate in field trips.

WATER ACTIVITIES: I hereby GIVE DO NOT GIVE my consent for my child to

participate in water activities:

Splash/Wading Pool Sprinkler Play Water Table Play Swimming Pool

Sand & Water Play Other Water Activities provided by the Facility
PHOTOGRAPHY: I hereby GIVE DO NOT GIVE my consent for my child to be
photographed to use in the classroom for decorations and projects.

MOVIES: I hereby GIVE DO NOT GIVE my consent for my child to watch videos
that are age and content appropriate.

RELEASE: I hereby GIVE DO NOT GIVE my consent for my child to be released to

the care of a sibling under 18 years old, if applicable.
An adult employee of Milestone Learning Preschool has my permission to administer the
following:

Sun block (30 SPF) No Sun Bug Repellent No Bug Repellent

SCHOOL-AGE CHILDREN:
My child attends
Name of School School Telephone No.

Address

My childs immunization record is on file at the school and all immunizations and tuberculosis
test results are current. Vision and Hearing screening records are also on file. YES NO
________________________________________________ ________________________
Parent/Legal Guardian Signature Date
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RECEIPT OF WRITTEN OPERATIONAL POLICIES:
I acknowledge receipt of the facilitys operational policies including those for
discipline and guidance.

I am aware that the Registration fees are Non-Refundable and Non-Applicable

to tuition.

I agree to pay the total weekly tuition on Monday for the upcoming week.

I understand that according to the preschools regulations, it is my

responsibility to escort my child into and out of the facility as well as sign them in
and out, daily, at the front counter.
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By signing below, I am fully acknowledging receipt of MILESTONES
PARENT INFORMATION GUIDE. Additionally, I have read and agree to
the Policy and Tuition Agreement for Milestone Learning Preschool.

________________________________________________ ______________________
Childs Name Age

________________________________________________ ______________________
Parent/Legal Guardian Signature Date

________________________________________________ _____________________
MLP Director Date

Where Focusing on Achievement Begins