Noah S Ark Learning Center Application for Enrollment

Application for Enrollment Office use only: Class:______Days:______

Date of Application:______

Child’s Name ______Birthdate: ______

Gender: Male Female

Father’s Name:______Mother’s Name: ______

Home Address:______

Cell Phone:______Email Address :______

Name and Ages of Siblings:______

Marital Status of Parents: ( )Married ( ) Separated ( ) Divorced ( ) Widowed

(If divorced, person having legal custody of child:______

Father’s Contact #: ______Mother’s Contact #:______

Father’s Employer:______Mother’s Employer:______

AUTHORIZED PICK-UP PERSONS Primary Pick-Up Person:

MOM/DAD ______

**Check below if also EMERGENCY CONTACTS (in addition to parents)

1. Name:______Emergency contact:

Phone:______Relationship: ______

2. Name:______Emergency contact:

Phone:______Relationship: ______Noah’s Ark Learning Center Application for Enrollment 3. Name:______Emergency contact:

Phone:______Relationship: ______

MEDICAL INFORMATION:

Does your child have any medical problems or conditions of which we should be aware? (including prolonged illness, serious accidents, surgeries…) If yes, please give details.

Child’s Physician: ______Physician’s Phone:______

List any on-going medications your child takes: ______

List any allergies:______

CONSENT FOR EMERGENCY CARE

I, ______do hereby request and give my consent to the Director of the Noah’s Ark Learning Center, or his/her duly appointed representative, for said child to receive such medical or surgical aid as may be deemed necessary and expedient by a duly licensed or recognized physician or surgeon in case of an emergency when the parents cannot be reached. I also authorized necessary transportation by an emergency vehicle.

Child’s Name:______Signature:______

Date: ______

RELEASE

In consideration of permission granted my child, ______by Noah’s Ark Learning Center to attend this facility and its activities, I release and discharge Noah’s Ark Learning Center, its agents, employees, and officers, from all claims, demands, actions, judgments, and executions which the undersigned , ever had, or now has, or may have, or claim to have against Noah’s Ark Learning Center, its successors and assignees, for all personal injuries, known or unknown, and injuries to property, real or personal, caused by, or raising out of activities at Noah’s Ark Learning Center.

I, the undersigned, have read this release and understand all its terms. I execute it voluntarily and with full knowledge of its significance.

Date Signed:______Signature:______

Print Parent Name:______

Address: ______

City, State, Zip Code:______