Where Little Minds Grow Registration

WHERE LITTLE MINDS GROW

Where Little Minds Grow PreK 3 and 4 Registration, ages 2-5

Fill out the form below to confirm your spot now!

Personal Information

Parent's First Name*

Parent's Last Name*

Email*

Child's First Name*

Child's Last Name*

Address*

Gender

MaleFemaleOther

Child's Date of Birth

Parent/ Guardian Information

First Name*

Last Name*

Phone*

Email*

Address*

Occupation*

Emergency Contact

First Name*

Last Name*

Phone*

Email*

Any medical concerns? *

PLease Upload Birth Certificate

Please upload DOHMH Medical Form

Health Declarations

Please fill-up this form as required by the Government that will require you to declare any illness and provide information that will aid in contract tracing, should the need arise. Be sure that the information you give is accurate and complete. All the information submitted shall be encrypted, and strictly used only in compliance to law, guidelines, and ordinances, in relation to business operation in light of COVID-19 response.

Do you or your child have any kind of allergies?

YesNo

Please specify*

Is your child taking any kind of medications that requires attention?

YesNo

Please specify*

CHILD’S PRIMARY CARE PHYSICIAN’S NAME/ GROUP:

PHYSICIANS PHONE NUMBER:

PREFERRED HOSPITAL:

Declaration and Consent

AGREEMENTS

I consent to emergency medical treatment for my childI consent for my child to take part in neighborhood trips (i.e., library, park and playground) away from the program under proper supervisionI provided information on my child’s special needs to the program to assist in caring for my childI understand the program must give parents, at the time of enrollment of a child, a written policy statement as required by regulationI agree to review and update this information whenever a change occurs and at least once every year

By signing this form, I declare that the information I have given is true, correct, and complete. I understand that failure to answer any question or giving a false answer can be penalized in accordance with the law.

Signature*

Date*

Username*

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Where Little Minds Grow

An interactive, inclusive and multi-sensory language based approach for successful learning. Group or individual sessions available.

Where Little Minds Grow Registration

Where Little Minds Grow PreK 3 and 4 Registration, ages 2-5

Fill out the form below to confirm your spot now!

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Where Little Minds Grow

Socialization

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