RHDS Registration Form - Riverland Hills Baptist Church

RHDS Registration Form2012-2013 School YearPhone: 798-2716 Fax: 753-6984Child’s Full Legal Name: __________________________________________(circle one) Male or FemalePreferred name: _________________________________DOB: _________________________Parent(s) Name: ____________________________________________ Home Phone: (___)_______________Home Address: ____________________________________________City/Zip:______________________A NON-REFUNDABLE REGISTRATION FEE OF $115.00 MUST ACCOMPANY THIS FORM.Application Status: Application for Preschool Class: (9:00-12:00)____Member of Riverland Hills____2-Year-Old ____MWF ____TTH ____5 days____Currently enrolled____PreK3 ____MWF ____TTH ____5 days____Previous Child enrolled____5 Day PreK4____New to Riverland Hills Day SchoolExtended Care: (Does not include the hours of 9-12)Check Here if you do not need Extended Care.ArrivalTimeDepartureTimeMonday Tuesday Wednesday Thursday FridayList of previous programs: ____________________________________________________________________________________________________________________________________________________________________________How did you learn of our program? ____________________________________________________________Does your family attend church? Y N (circle one)If yes, which church? ______________________________For Office Use Only *Required for AdmissionDate:Paid:Ck#CashEnteredTuitionBilledSchedulePermissionto photo:YNDirectoryPermission:YNB. Cert.*DSS2900Form *Immun.* Discipline* Dev. HlthHistory

Family Information:Mother’s Name: ___________________________________________________________________________Home phone: (___)______________ Cell Phone: (___)_____________ Work Phone: (___)_______________Employed by: _______________________________________________ Occupation: __________________Home Address: ______________________________________ City/zip _______________________________Email address: _____________________________________________________________________________Father’s Name: ___________________________________________________________________________Home phone: (___)______________ Cell Phone: (___)_____________ Work Phone: (___)________________Employed by: _________________________________________________ Occupation:__________________Home Address:__________________________________________________ City/zip ___________________(if different from one listed above)Email address ______________________________________________________________________________Are parents married? Y N (circle one) If not, are there step-parents? Y N (circle one)Are there any custody issues? Y N (circle one) If yes, the Day School must have copies of legal documents on file ifthere are any special circumstances of which we need to be aware.Student DirectoryI/We give my/our permission _____________________________________________ to publish name,Signature of parent required for permissionaddress, home phone number and email address in a Student Directory, or to give information to other parentswhen they ask for contact information.Permission to photographI/We give my/our permission to photograph ___________________________________ our child in theSignature of parent required for permissionclassroom. Photographs are taken by staff members for documentation and activities, and other parents takephotographs during parties. Photographs may be used in slide shows, and for advertising.Emergency Information/Authorization for pick-up:Family Code Word ___________________The following listed individuals have permission to pick up my child or to be contacted in case of an emergency. I understand that Iwill need to fill out an “Individual Child Check out Form” each time someone other than a person on this list is to pick up my child,and turn it in to the office. The Day School Staff Members are authorized to request a photo ID from anyone with whom they areunfamiliar, even if listed on this form.1. Name: ______________________________________________________________ Relationship: _______________________home phone: (___)__________________ work phone: (___)____________________ cell phone: (___)_____________________2. Name: _____________________________________________________________ Relationship: _______________________home phone: (___)__________________ work phone: (___)____________________ cell phone: (___)_____________________3. Name: ______________________________________________________________ Relationship: _______________________home phone: (___)__________________ work phone: (___)____________________ cell phone: (___)_____________________

The following person(s) may not pick up my child. Legal documentation must be on file in the DaySchool office.Name: _____________________________________Relationship _________________I (We) have read the Riverland Hills Day School policy on authorization for pick up of children. I (We)understand that a photo ID may be requested if a staff member is not familiar with a person who is on the pickup authorization list. I (We) understand that whenever a person other than those listed is to pick up a child, aparent must complete an “Individual Child Check Out Form” and turn into the Day School office. A personnot on the pick up list should have a photo ID available for the staff to see.Parent(s) Signature: ___________________________________ Date: _______________Health/Medical Information:List any allergies, health concerns, special medical treatments, and/or daily medication involving your child:____________________________________________________________________________________________________________________________________________________________________________________Child’s Doctor: _______________________________________________ Phone _______________________Child’s Dentist: _______________________________________________ Phone _______________________Health Insurance Information: ______________________________________________(This information is needed in the event your child has to be transported to the hospital)Medical Treatment:I/We _____________________________give my/our permission to Riverland Hills Day School Staff to takeSignature of parent required for permissionwhatever emergency measures are judged necessary (for first aid or emergency evacuation) for the care andprotection of my child while under the supervision of the Day School.It is understood that in some medical situations, the staff will need to contact the local emergency resourcebefore the parent, child’s physician and/or other adult acting on the parent’s behalf. If the local emergencyresource deems it necessary to transport my child, it will be to the closest hospital facility, unless one is namedotherwise above. A staff member from RHDS will accompany my child, and will stay at the hospital facilityuntil the parent or emergency contact arrives. I authorize Riverland Hills Day School staff to obtain emergencymedical treatment for my child if necessary.If the Day School is unable to reach the parent, the list of contacts listed in the emergency information on theprevious page will be called in the order in which they are listed. I understand that any medical expenseincurred as a result of transporting or treatment will be my responsibility.I understand that accidents can occur while children play together, and I agree not to hold Riverland HillsBaptist Church liable for any unforeseen accidents that may occur.Parent(s) Signature __________________________________________________ Date __________________

Developmental Health History 2012-2013The following information will go to your child’s classroom teacher. Please be thorough with the informationso that we can best know how to take care of your child.Child’s Name ________________________Birth Date _____________________Physical HealthDoes your child have any food allergies? If so, please list the allergies and instruct us how to handle theseallergies. (In severe cases, an allergy plan from your physician may be required)______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Does your child have any other allergies? If so, please list the allergies and instruct us how to handle them onsite. _______________________________________________________________________________________________________________________________________________________________________________Has your child had any health problems in the past? Please list. __________________________________________________________________________________________________________________________________________________________________________________________________________________________Any current health problems? _________________________________________________________________Does your child take any medication regularly? If so, what?_________________________________________(Please refer to the parent handbook for information about administering medicine at school.)Has your child ever been hospitalized? _________________________________________________________Does your child have any recurring chronic illness or health problem (such as asthma or frequent earaches, forexample)? ________________________________________________________________________________Does your child have a disability that has been diagnosed (such as cerebral palsy, seizure disorder,developmental delay, speech delay, etc)____________________________________________________________________________________________________________________________________________________________________________________Do you have concerns about your child in any of the following areas: (circle any that apply)Eyes (seeing) Ears (hearing) Teeth SpeechGross Motor (walking, running, moving) Fine Motor (use of hands in drawing, puzzles, small toys)Please explain any concerns you have in more detail ________________________________________________________________________________________________________________________________________Family InformationList names and relationship of adults living in same household: (if parents share custody, please giveinformation about both households) ____________________________________________________________________________________________________________________________________________________List names and ages of children living in the same household: _________________________________________________________________________________________________________________________________

If parents share custody of child, please describe the visitation schedule: _________________________________________________________________________________________________________________________With which adults do your child have frequent contact? ____________________________________________________________________________________________________________________________________Daily LivingDescribe your child’s typical eating pattern. ______________________________________________________What foods does your child like? ______________________________________________________________Dislike? __________________________________________________________________________________Is your child completely toilet trained? ________Potty words used in home.____________________________Does your child take naps? ___________________ Does your child fall asleep easily? __________________Does your child have any rituals as a prerequisite to fall asleep? _____________________________________Does your child have a special item to fall asleep/comfort self? ____________What? _________________Social Relationships/PlayWhat ages are your child’s most frequent playmates? _____________________________________________Is your child friendly? _______________ Aggressive? _______ Shy? _______ Withdrawn? ___________Does your child play well alone? _______________________ With other children? ____________________What types of activities of activities does your child enjoy? ________________________________________What frightens your child? _________________________________________________________________What comforts your child? _________________________________________________________________How is discipline handled in the home? _______________________________________________________Please share any additional information you would like us to know about your child.______________________________________________________________________________________________________________________________________________________________________________________________________________________