KING DAVID ADADEMY ENROLLMENT FORM

Entranse Date ___________________                       Withdrawal date_____________________

CHILD INFORMATION
Child’s Name
	Nickname
	SS#	
Date of Birth
	Gender 	Age	Phone	
Home Address
	
PARENT/GUARDIAN INFORMATION
Parent/Guardian Name
	
Relationship to Child
	Primary Language	
Home Address
	
Home Telephone
	Cell Phone Number
	
Business Address
	
Work Hours
	Work Phone	
Email Address

Parent/Guardian Name
	
Relationship to Child
	Primary Language	
Home Address
	
Home Telephone
	Cell Phone Number
	
Business Address
	
Work Hours
	Work Phone	
Email Address

Child`s Living Arrangements (Both Parents, Mother, Father, Other)
	
Child`s Legal Guardians (Both Parents, Mother, Father, Other)

Parent/Guardian Signature:                                                     Date:
	
PRESCHOOL DEVELOPMENT HISTORY FORM

Child’s Name:                                                Date of Birth:

Please answer the following questions regarding your child’s development. Theinformation you provide will assist us in caring for your child. Thank you.
DEVELOPMENTAL HISTORY
Is your child right or left handed?
	
Can your child dress him or herself?
	
SOCIAL RELATIONSHIPS
Has your child had any previous experience with other children or in group care?
	
Does your child know other children in this program?
	
Does your child have any special toys and/or activities?
	
Does your child have any fears? (the dark, animals, etc.)
	
How do you comfort your child?
	
How does your child comfort him/herself? (thumb-sucking, nail biting, etc.)
	
How do you discipline your child?
	
Have there been any major events/changes in your family life in the past year? (moving, deaths,
births, divorces, etc.	
What would you like your child to gain from this child care experience?
	
EATING HABITS
Does your child have any favorite foods?
	
Does your child feed him/herself?
	
TOILETING
Does your child indicate when he or she needs to use the bathroom?
	
Is your child ever reluctant to use the bathroom?
	
Does he/she wear a diaper for nap or nighttime?
	
SLEEPING HABITS
Does your child take naps?                 From:                                               To:	
When does he/she go to bed at night? Wake in the morning?
	
Describe your child’s bedtime needs and/or routine. (story, dolls, etc.)
	
CHILD’S DAILY SCHEDULE
Please describe your child’s schedule on a typical day. Include mealtimes, television times.
Independent and group activities, etc. Give approximate times for each activity/routine.

ADDITIONAL INFORMATION
Please list any additional information you would like to share with us regarding your child.

Parent/Guardian Signature:                                                                        Date:	

KING DAVID ADADEMY
EMERGENCY AUTHORIZATION AND CONSENT FORM

CHILD’S MEDICAL INFORMATION
MEDICAL HISTORY (Please write “NONE” if there are none)	
Child’s Name
	Date of Birth
	
Allergies/Reactions/Treatment
	Current Medications
	
Special Physical Conditions, Disabilities, Chronic Health conditions
	
Emergency Medical/Dietary Information/Religious Restrictions
	
Behavioral Issues
	
Other Emergency Health Concerns

INSURANCE INFORMATION (Optional)	
Medical Insurance Company
	Policy Number
	
Other Coverage (Include Dental)
	
Child’s Physician/Clinic
	Phone	Address

City                 Zip
	
Child’s Dentist
	Phone	Address

City                 Zip

MEDICAL TREATMENT CONSENT

I hereby give King David Academy permission to administer basic first aid and/or CPR to my

child _________________________ and/or take my child to a hospital and to secure medical
                               (Name)
treatment when I cannot be reached or when delay would be dangerous to my child’s health.
In the event of an emergency, I hereby authorize the KING DAVID ADADEMY staff to have my
child transported to the nearest medical facility or to _______________________ and
secure necessary medical treatment including, but not limited to: hospitalization, injections,
anesthesia, and/or surgery. In the event that I cannot be reached, I hereby give
permission to the physician attending to my child to secure and administer treatment as
necessary. I understand that the staff will make every effort to notify me of the
emergency immediately.

Parent/Guardian Signature:                                                                 Date:
	
EMERGENCY CONTACTS AND PICK-UP AUTHORIZATION FORM

EMERGENCY CONTACTS
List Parents/Guardians first, then, in order to be contacted, three additional individuals to be
contacted in an emergency and non-emergency, if you cannot be reached. Please note that persons
listed as “Emergency Contacts” are automatically authorized to pick up your child from the program.*
List beeper number under cellular with (B) notation.	
Parent/Guardian	Relationship
	
Home Phone 
	Work Phone	Cellular Phone	
Parent/Guardian
	Relationship
	
Home Phone
	Work Phone	Cellular Phone
	
Name

Address
	Relationship
	
Home Phone
	Work Phone	Cellular Phone
	
Name

Address
	Relationship
	
Home Phone
	Work Phone	Cellular Phone
	
Name

Address
	Relationship
	
Home Phone
	Work Phone	Cellular Phone

PICK-UP AUTHORIZATION
Please list below individuals who are authorized to pick up your child from the program. These persons
are in addition to those listed under “Emergency Contacts.”* List beeper number under cellular with
(B) notation.
	
Name

Address	Relationship
	
Home Phone
	Work Phone	Cellular Phone
	
Name

Address
	Relationship
	
Home Phone	Work Phone	Cellular Phone

Parent/Guardian Signature:                                                     Date:
	
*Biological parents and legal guardians listed on enrollment forms are automatically authorized to pick
up your child unless the program is given a copy of a current court ordered custody agreement or
restraining order. All individuals authorized to pick up your child from the program must be at least
16 years of age. A license or other positive proof of identification must be shown at pick-up time. If
you wish to change, add, or delete any of these authorizations, you must do so in writing. Please note
any special instructions regarding these individuals.
KING DAVID ADADEMY
AUTHORIZATION AND CONSENT FORM

PHOTOGRAPH PERMISSION SLIP

We love to have pictures of thing we do at school like special guests, projects we are
working on, and center wide events. At times we may be featured in the KDA newspaper and KDA website. Therefore, we need your permission to capture these special moments on film.

I give permission to Campus Kinder Haus to take pictures of my child’s class so I can see what they are doing while I am at work.

Child’s Name______________________________________________

Parent/Guardian Signature:                                                        Date:

WALKING PERMISSION SLIP

I give permission for my child to go on a walking field trip in the immediate neighborhood. I understand that I will be notified, in advance, if my child will be going on a walking field trip.

I understand that there will also be a notice on the door of my child’s classroom if they are not in the room.

Parent/Guardian Signature:                                                       Date:

VIDEO PERMISSION SLIP

At times the center may videotape the children and their teachers for teacher observation,
parent/teacher conferences, or class viewing.

I give permission for my child to be videotaped while at KING DAVID ADADEMY

Parent/Guardian Signature:                                                      Date: