LITTLE TIGERS PRESCHOOL AND DAYCARE
Registration Form 2015-2016
CHILDS INFORMATION
Child's First Name____________________________________ Middle Name ______________________Last Name_____________________________________
Child’s Sex_______ Age________ Child’s Birthdate __________________________ Child’s Nickname_____________________________________________________
Child’s Public School ____________________________________________________________ Grade_____________ Teacher _________________________________
PARENTS INFORMATION
Mother’s First Name___________________ Middle Initial_______ Last Name______________________________ Birthdate ________________________________
Mother’s Address_____________________________________________________________________ City___________________ Zip Code______________________
Mother’s Employer_________________________________________________________________ Work Phone ___________________ Extension_______________
Mothers Home Phone ______________________ Mother’s Cell Phone ____________________ Mother’s Email _____________________________________________
Mother’s Marital Status: Married________________Separated________________Divorced________________Single___________________
Father’s First Name___________________ Middle Initial_______ Last Name______________________________ Birthdate ________________________________
Father’s Address__ ___________________________________________________________________ City___________________ Zip Code______________________
Father’s Employer_________________________________________________________________ Work Phone ___________________ Extension_______________
Father’s Home Phone ______________________ Father’s Cell Phone ____________________ Father’s Email _____________________________________________
PARENT TO CONTACT IN CASE OF AN EMERGENCY: ________________________________ Phone _______________________________________________
EMERGENCY CONTACT (OTHER THAN A PARENT)
First Name ______________________Middle Initial __________Last Name_________________________ Birthdate ________________ Relationship ______________
Address__________________________________________________________________ City__________________ Zip Code _____________ Phone________________
What arrangements have you made for your child's care in the event of illness? ________________________________________________________________________
__________________________________________________________________________________________________________________________________________
AUTHORIZED PICKUPS
Your child will not be released to any person not specifically authorized by you. Please list below all persons allowed to pick up your child other than the mother,
father and emergency contact. They will have to show picture identification before your child will be released.
First Name ____________________Middle Initial __________ Last Name___________________ Birthdate ________________ Relationship to Child______________
Address_______________________________________ City_________________________________ Zip Code ___________ Phone Number _____________________
First Name ____________________Middle Initial __________ Last Name___________________ Birthdate ________________ Relationship to Child______________
Address_______________________________________ City_________________________________ Zip Code ___________ Phone Number _____________________
First Name ____________________Middle Initial __________ Last Name___________________ Birthdate ________________ Relationship to Child______________
Address_______________________________________ City_________________________________ Zip Code ___________ Phone Number _____________________
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Developmental Record
Are there any special needs or concerns about your child which may require special training or emergency procedures our
staff should be trained for?____________ If yes, an individual plan of care must be competed and please explain:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Is Child adopted _________At what age __________Has child been told______________ List illnesses Child has had_________________________________________
Serious accidents_________________________________________________ Operations_________________________________________________________________
ALLERGIES & MEDICAL CONDITIONS
Allergies_______________________________________________________________ Reaction to Allergies _________________________________________________
Is Child susceptible to colds? ____________________________________________ Does Child tire easily? __________________________________________________
Medical Conditions (Asthma, Diabetic, etc.) _____________________________________________________________________________________________________
Any nervous habits (thumb sucking, etc.)________________________________________________________________________________________________________
Does Child have any abnormalities, handicaps or physical restrictions? ______________________________________________________________________________
If there are any limitations on the Child's activities, please give instructions and recommendations for handling. ____________________________________________
Language
Is Child easily understood? _______________Any speech difficulties? _______________________________________________________________________________
Toileting
Does Child indicate toilet needs? _____________ Does Child need assistance at toileting? __________________________ Is Child Potty Training? _________________
Resting
Does Child normally rest during the day? __________________________________Any rest or sleeping problems? __________________________________________
Eating
Does Child have a good appetite? ____________________________________Any food eating problems or restrictions? _______________________________________
Fears
What is Child afraid of? _____________________________________How has fear been handled? _____________________________________________________
Feelings
How does Child show anger? _______________________How does Child show tensions? _______________________________________________________________
Discipline
Methods of discipline used by parents? __________________________________How does Child respond to discipline? _____________________________________
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Group Experiences
Has the Child played with other children? _________________________________________________________Own age ________Younger ________Older _______
How does Child get along with other children? ________________________List any group experiences Child has had.______________________________________
Family Background
Names of brothers and sisters.____________________________________________________________Birthdays____________________________________________
Other persons living in the home._________________________________ Does Child have an outdoor play area? __________________________________________
What are Child's favorite playthings? _______________________________ Has Child had any unusual experiences? _______________________________________
Does Child exhibit any special behavior which concerns you? _________ If Yes, What are they _________________________________________________________
Why did you select Little Tigers for your Child? ________________________________________________________________________________________________
Are there any special activities or topics you would like presented in your Child's class? _______________________________________________________________
Do you have any special hobbies, skills or training you could offer the children at Little Tigers as a volunteer? (Music, art, crafts, dance etc.)
__________________________________________________________________________________________________________________________________________
Please provide us with a code word so that if you call the center and we do not recognize your voice we will have a word
that we can identify you with.
OUR CODEWORD IS __________________________________________________________________________
Hint__________________________________________________________________________________________
Signature of person enrolling Child____________________________________________
The registration fee is non-refundable unless the director does not accept the application due to full classrooms or not servicing a
school because there were only one or two children attending that school.
OFFICE USE ONLY
Registration Paid by Check ______Cash ________Card__________ State_______
Childs Start Date_________ Enrolled Date_________ Termination Date________
Director Signature____________________________________________________
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LITTLE TIGERS SCHEDULE
Little Tigers Preschool and Daycare Center shall provide the following services for
NAME______________________________________________________________________________________
Parent or Guardian: _______________________________________________Relationship ___________________
Preschool Only Program
Our Preschool hours are from 9:00 AM to 12:00 noon. Child must be fully potty trained!
Please Circle Days Needed: MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY
Daycare and Preschool Program
Please Circle Days Needed: MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY
Kindergarten Program
Please Circle Days Needed: MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY
School Attending: _____________________________________ Kindergarten Session: AM
PM
Monthly Transportation Fee for Bus Service to School $10.00 unless child attends Tukes Valley Schools
Before School Program
Please Circle Days Needed: MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY
After School Program
Please Circle Days Needed: MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY
Before & After School Program
Please Circle Days Needed:
MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY
Monthly Transportation Fee for Bus Service to School $10.00 for all School age programs unless child attends Tukes
Valley Schools as we get public busing for those students.
Tuition payments are due on the first day of attendance each week. Monthly payments are due on the 1st of each month.
Accounts 2 weeks past due will be terminated immediately until account is brought up to date! Fill out Arrival and
departure time for all programs.
Approximate arrival time ______________________Approximate departure time___________________________
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STATEMENT OF UNDERSTANDING
THE FOLLOWING PERTAINS TO POLICIES SET FORTH IN THE PARENT HANDBOOK. BY INITIALING EACH
SECTION I AM AGREEING THAT I HAVE READ AND UNDERSTAND THE POLICIES.
Policy
Hours of Operation
Application Procedures & Paperwork
Annual Registration Fee
Tuition
Payment and Late Fees
Departure and Arrival
Sign In and Out Procedures
Child Vacation Days
Holidays The Center Is Closed
Medical Emergencies
Health Policy
Disaster Plan
Emergency Procedures
Pesticide Policy
Child Abuse
Parent
Initials
Policy
Parent
Initials
Parent Parking
Divorce or Separation
Transportation To Schools
Food Service And Times
2% Chocolate Milk
Lunch Time
Child Illness
Medication
Rest and Relaxation Time
Afterschool Homework Time
Clothing and Personal Items
Discipline & Guidance
Potty Training
Birthdays
Share Day
I am aware of the conditions stated above and by signing my signature I agree to abide by the above policies and
requirements.
Parent or Guardians Signature_______________________________________________Date______________________
BY INITIALING EACH SECTION I AM AGREEING THAT I HAVE GIVEN MY PERMISSION FOR MY CHILD TO DO THE
FOLLOWING.
Permission For
Transportation To And From Public School Each Day
Spontaneous Field Trips By Vans Or Walking
Watching “PG” Rated Movies
To Be Photographed And Photos Displayed Around The Center
Play the PlayStation Games
Computer Internet Access
Play and jump in our jump house
Use of hand sanitizer
Change rooms for short periods when needed to accomplish a smooth transition
Visit in a classroom with a previous teacher
Parent Initials
By signing my signature I hereby give my permission for my child to do the above initialed activities.
Parent or Guardians Signature ______________________________________Date______________________
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LITTLE TIGER’S HEALTH INFORMATION
Child’s Name____________________________________________Birthdate____________________________________________
Mother ________________Work Phone ____________Father _________________Work Phone______________________________
Doctors Name___________________________ Hospital to Transport to If Needed_________________________________________
Doctors Phone ____________________________
Address___________________________________________________________
Date of last doctor’s visit____________________________ Exempt from Immunizations (yes or no): _______________________
Date and Type of Immunizations received in 2015-2016 (Example DTAP 06/12/13) _______________________________________
___________________________________________________________________________________________________________
Does your child have a Dentist?
No (if no,
Yes
please write “see emergency contact” in the dentist name
section)
Dentist’s Name __________________________________________Phone # ______________________________________________
Dentist’s Address _____________________________________________________________________________________________
Does this child have any specific
Health problems which the staff
Should be aware of?
IF SO, EXPLAIN: __________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Has the child had any serious
Illness, accident or surgery.
IF SO, EXPLAIN: ___________________________________________________________
__________________________________________________________________________
Communicable diseases (mumps
Measles, chicken pox, ect.)
IF SO, EXPLAIN: ___________________________________________________________
__________________________________________________________________________
Existing Medical Conditions which may require special needs or attention_____________________________________________________
________________________________________________________________________________________________________________
How are the above conditions normally treated________________________________________________________________________
________________________________________________________________________________________________________________
If the child appears to be experiencing the above conditions, what actions do you want Little Tigers Staff to take._______________________
_________________________________________________________________________________________________________________
Medications taken regularly: ________________________________________________________________________________________
Special Instructions Concerning Your Child
CONSENT FOR MEDICAL CARE & TREATMENT OF A MINOR CHILD
I, ________________________________the parent or legal guardian of _____________________________________________________
Authorize and consent to medical, surgical & hospital care, treatment & procedures to be performed for my child by a licensed physician or
hospital when deemed necessary & advisable by the physician to safeguard my child’s health. If I cannot be contacted, I hereby waive my
right of informed consent to such treatment.
Signature of Parent of Legal Guardian____________________________________________Date_________________________________
This consent shall remain in effect until rescinded in writing.
Address_____________________________________________City____________________State_______________ Zip Code ________
Home Phone ____________________________Work Phone _______________________Cell ___________________________________
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