The Ivy Academy of Early Learning

Enrollment form


Child’s Information:

Name of Child:   
Child’s DOB:   
Child’s Gender:   
Child’s SSN/ITIN:   

Parent/Guardian Infomation

Personal Information (Parent 1)

Name:   
DOB:   
Relationship to child:   
SSN/ITIN: 
Driver’s License:   
Address:   
Phone:   
Cell:   
Email:   

Employment Information (Parent 1)

Employer:   
Address:   
Phone:   
Working Hours:   

Personal Information (Parent 2)

Name:   
DOB:   
Relationship to child:   
SSN/ITIN:    
Driver’s License:    
Address:   
Phone:   
Cell:   
Email:   

Employment Information (Parent 2)

Employer:   
Address:   
Phone:   
Working Hours:   

Emergency Contacts

Emergency contacts to notify if the parents/guardians cannot be reached.

Emergency Contact 1

Name:  
Relationship to child:   
Address:  
Phone:   
Cell:   
Authorized to pick up child (with further written consent):   

Emergency Contact 2

Name:  
Relationship to child:   
Address:  
Phone:   
Cell:   
Authorized to pick up child (with further written consent):   

Emergency Contact 3

Name:  
Relationship to child:   
Address:  
Phone:   
Cell:   
Authorized to pick up child (with further written consent):   

Child’s Health

Physician’s Name:   
Physician’s Address:   
Physician’s Phone: 

Last Tetanus shot:   
Allergies to medication:   
Regularly taken medication:   
Medical concerns:   
Physical handicaps:   
Food restrictions:  
Food dislikes:   
Special names for objects:  
Fears:   
Special needs:  
Is the child toilet trained:   
Other information that would be beneficial for your child’s teacher to know:   

General Information

Pledge of Allegiance

 

Trips, Excursions, and Public Facilities Authorization

 

Emergency Medical Information/Authorization

I/We give The Ivy Academy of Early Learning Inc. permission to take my child to an approved hospital emergency/immediate care center and/or call “911” in case of sudden illness or accident. Additionally, I specifically constitute and appoint The Ivy Academy of Early Learning Inc. my true and lawful attorney, for purposes of authorizing medical treatment to, and the performance of any procedure (basic first aid and CPR) determined to be necessary before/after consultation with Emergency or Family Physician on my child.

Program Contract

Days per week:  
Hours of care (time of day):   
Rate of Pay:    

Agree & Sign

I attest that the information I provided is true. By signing below I agree to the terms of the information that was provided to me in the Parent Information/Rate Sheet, and I understand all of what I have read and signed.

Leave this empty:

The Ivy Academy of Early Learning http://theivyacademy.org
Signature Certificate
Document name: Enrollment form
Unique Document ID: 3ca1f77926427ec7965bfc1b4fba48853b2b7fcf
Timestamp Audit
July 4, 2017 10:25 am CSTEnrollment form Uploaded by Amy Hitchinson - ahitchinson@theivyacademy.org IP 165.225.80.244
February 20, 2018 11:06 am CSTDil Ahdan - dil@1da.co added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 165.225.80.244
February 20, 2018 11:06 am CSTAmy Hitchinson - theivyacademy@ymail.com added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 165.225.80.244
February 20, 2018 11:06 am CSTLorena Delgado - ldelgado@theivyacademy.org added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 165.225.80.244