GAN YELADIM PRESCHOOL ADMISSION FORM 2019/2020 5780
NAME OF CHILD___________________________________ AGE_______________
DATE OF BIRTH______________________________HOME PHONE_____________
ADDRESS_____________________________________________________________
PLEASE USE THE BACK OF THIS FORM TO TELL US ABOUT YOUR CHILD
PARENT’S NAME _____________________ PARENT’S NAME_______________________
ADDRESS_____________________________ ADDRESS_____________________________
HOME PHONE________________________ HOME PHONE__________________________
CELL_______________________________ CELL__________________________________
EMAIL ADDRESS_____________________ EMAIL ADDRESS______________________
OCCUPATION _______________________ OCCUPATION _______________________
WORK ADDRESS_____________________ WORK ADDRESS______________________
WORK PHONE _______________________ WORK PHONE ________________________
FIELD TRIP/EMERGENCY CARE RELEASE:
I GIVE MY CONSENT FOR MY CHILD TO TAKE PART IN FIELD TRIPS AND/OR EXCURSIONS UNDER PROPER SUPERVISION:
___ YES ___NO
IN THE EVENT THAT MY CHILD BECOMES ILL OR INJURED, I GIVE MY PERMISSION FOR GAN YELADIM STAFF TO SEEK EMERGENCY MEDICAL CARE: YES____ NO ____
______________________________________ ____________________________
PARENT’S SIGNATURE DATE
IF A PARENT CANNOT BE REACHED IN THE EVENT OF AN EMERGENCY, PLEASE CALL:
NAME____________________________ PHONE ______________ RELATIONSHIP__________
NAME ___________________________ PHONE ______________ RELATIONSHIP__________
NON-PARENT PICK UP:
I AUTHORIZE THE FOLLOWING PEOPLE TO PICK UP MY CHILD FROM GAN YELADIM:
NAME____________________________ PHONE_______________ RELATIONSHIP__________
NAME____________________________ PHONE_______________ RELATIONSHIP__________
MEDICAL/DENTAL INFORMATION:
CHILD’S PHYSICIAN ___________________________________ PHONE __________________
CHILD’S DENTIST _____________________________________ PHONE __________________
DOES YOUR CHILD HAVE ANY ALLERGIES OR TAKE DAILY MEDICATIONS? YES___ NO ___
IF YES, PLEASE EXPLAIN IN DETAIL________________________________________________
______________________________________________________________________________.
PLEASE INCLUDE A DEPOSIT OF $100.00, WHICH WILL BE APPLIED TO YOUR CHILD’S FIRST MONTH OF TUITION.