Student Enrollment Form (Page 2 of 3) in pdf

STUDENT ENROLLMENT FORM

Medical Information/Treatment

Physician Name

Address

Phone #

City

Zip

Insurance Provider

Policy #

Please list any special limitations or health information we should know about your child's dietary restrictions, allergies (food, insect bites,

medication, etc.), and health conditions. If none, please indicate by writing "none".

Signs/Symptoms to look for:

If signs/symptoms appear, do this:

Comments/other medical procedures that may be needed:

To prevent incidents:

Immunization Records: Please attach record to enrollment form

What communicable diseases has the child had?

Measles (Big Red) _______ Measles (3 day)________

Mumps __________

Chicken Pox __________

Whopping Cough ________

Other ________________________________________

Any Chronic physical problem?

Type of Accommodations needed*:

Any developmental or learning need?

Type of Accommodations needed*:

* If special accommodations are needed, a current copy of the child's IEP or ISP is required.

MEDICATIONS

Are any medications given regularly? (Please list medications and reasons)

SPEECH

Rapid

Slow

Moderate

Clear

Talks Constantly

Describe your child's speech (circle):

Uses Many Words

Uses Few Words

Talks Only During Play

Seldom Speaks

TOILETING

Does your child have any special toileting needs?

I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, if I cannot be reached,

I authorize AlphaBEST Education Inc. to transport my child to the nearest hospital or medical facility and to secure for my child the necessary medical facility and

to secure for my child the necessary medical treatment. I understand the employees in the extended day program are trained in the basics of First Aid/CPR, and I

authorize them to give my child First Aid and/or CPR if necessary. If necessary, have your child's health practitioner review the information you provide above

and sign and date where indicated. I understand that the Director will notify me whenever my child becomes ill and I agree to pick-up my child, or make

arrangements to have my child picked up by an authorized individual, as soon as possible if so requested by AlphaBEST. I understand that I am required to inform

the AlphaBEST program within 24 hours or the next business day after my child or any member of my immediate household has developed any reportable

communicable disease, as defined by the State Board of Health, except for life threatening diseases which must be reported immediately.

Date

Parent Signature

Schooling

Please list any previous school and/or child care center enrollment

Name of school/center

City/Town

State

Dates of Attendance

Name of school/center

City/Town