Enrollment Application

Child's Name

Mother's Name

Child's Birthday

Father's Name

Address

Mother's Home Phone

Mother's Work Phone

Mother's Cell Phone

Emergency Contact Person #1

Emergency Contact Person #2

Father's Home Phone

Father's Work Phone

Father's Cell Phone

Emergency Contact #1's Phone

Emergency Contact #2's Phone

Do you have a backup care provider? If so, please provide name and contact info:

Beginning date needing care

Care options, please choose one:

Full-time Care (4 days/40 hours/week) Monday - Thursday 7:30am-5:30pm

Part-time Care (2 days/20 hours/week) Monday and Wednesday 7:30am-5:30pm

Part-time Care (2 days/20 hours/week) Tuesday and Thursday 7:30am-5:30pm

Time you plan to drop your child off

Time you plan to pick you child up

Child's general state of health

Doctor's Name

Dentist's Name

Doctor's Phone

Dentist's Phone

Are you child's immunizations up to date?

Yes

Does your child have any allergies? If so, please describe:

Does your child have any medical conditions which I should be made aware of?

Does your child have any speech, hearing, or visual problems?

Would there be any restrictions to play or activities?

Has your child ever been in child care before? If yes, please specify type (center, family, daycare, Grandma, etc.)

Was it a positive experience?

How does your child feel about starting preschool?

Are there any recent traumatic situations the child has been exposed to such as a death in the family, divorce, new sibling, etc.?

What is your normal method of discipline?

What is your child's temperament? Are they easy going, hard to please, demanding, aggressive, etc.

Are there any food restrictions?

What is your child's favorite food?

What foods does your child dislike?

Can your child be relied upon to indicate bathroom wishes?

What words does your child use for bowel movements and urination?

What time does your child awaken?

06:30 AM

What time does your child go to sleep at night?

07:30 PM

Do they sleep through the night?

Are there any siblings? Please name them and specify ages and gender.

Has your child had experience playing with other children?

What language(s) are spoken at home?

Does your child have any security objects such as a blanket, soother, bottle, toy, etc.?

What are your child's favorite activities, toys, books, or games?

Are there any other comments or information you would like to let me know about?

Any specific concerns?

Thanks for applying!

Enrollment Application

email

phone 608-717-9112

Enrollment Application

email greenhousenatureschool@gmail.com

phone 608-717-9112

email