<p>Application for Enrollment Office use only: Class:______Days:______</p><p>Date of Application:______</p><p>Child’s Name ______Birthdate: ______</p><p>Gender: Male Female</p><p>Father’s Name:______Mother’s Name: ______</p><p>Home Address:______</p><p>Cell Phone:______Email Address :______</p><p>Name and Ages of Siblings:______</p><p>Marital Status of Parents: ( )Married ( ) Separated ( ) Divorced ( ) Widowed</p><p>(If divorced, person having legal custody of child:______</p><p>Father’s Contact #: ______Mother’s Contact #:______</p><p>Father’s Employer:______Mother’s Employer:______</p><p>AUTHORIZED PICK-UP PERSONS Primary Pick-Up Person:</p><p>MOM/DAD ______</p><p>**Check below if also EMERGENCY CONTACTS (in addition to parents)</p><p>1. Name:______Emergency contact: </p><p>Phone:______Relationship: ______</p><p>2. Name:______Emergency contact: </p><p>Phone:______Relationship: ______Noah’s Ark Learning Center Application for Enrollment 3. Name:______Emergency contact: </p><p>Phone:______Relationship: ______</p><p>MEDICAL INFORMATION:</p><p>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.</p><p>Child’s Physician: ______Physician’s Phone:______</p><p>List any on-going medications your child takes: ______</p><p>List any allergies:______</p><p>CONSENT FOR EMERGENCY CARE</p><p>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.</p><p>Child’s Name:______Signature:______</p><p>Date: ______</p><p>RELEASE</p><p>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.</p><p>I, the undersigned, have read this release and understand all its terms. I execute it voluntarily and with full knowledge of its significance.</p><p>Date Signed:______Signature:______</p><p>Print Parent Name:______</p><p>Address: ______</p><p>City, State, Zip Code:______</p>