Applicant

Name:
Address:
Email:
Date of Birth:
Age:
SEX:MaleFemale
Eye Color:
Height:
Hair Color:
Weight:
Any Other Identifying Marks:
Date of Application : For: Infant Toddler Preschool/PreK School Age
Drop off time requested:
Pick up Time Requested:
Full DayHalf DayM T W TH F
Please check Location
HanoverSeekonkN. Smithfield

PARENT/GUARDIAN

Full Name:
Home Address:
Home Phone:
Home Fax:
Cell Phone:
Employer:
Occupation:
Address:
Phone:
Fax:
Email Address:
WorkHome

PARENT/GUARDIAN

Full Name:
Home Address:
Home Phone:
Home Fax:
Cell Phone:
Employer:
Occupation:
Address:
Phone:
Fax:
Email Address:
WorkHome

FAMILY INFORMATION

Student lives with (check all that apply):
MotherFatherStepmotherStepfatherGuardianOther
If the applicant’s parents are divorced, please indicate which parent has responsibility for:
Custody of student :
School related decisions :
Financial matters :
School registration materials :
Which language is spoken at home?
SIBLINGS:
Name:
DOB:
Current School:
Name:
DOB:
Current School:
Name:
DOB:
Current School:

AUTHORIZED PICK UP

Name:
Address:
Phone:
Relationship:
Name:
Address:
Phone:
Relationship:
Name:
Address:
Phone:
Relationship:
Name:
Address:
Phone:
Relationship:

GENERAL INFORMATION

In what ways do you expect your child to benefit from our program?
Describe your child using three adjectives:
What hobbies and interests does your child possess:
Your child’s eating habits: Favorite foods:
Least:
Eats with: hands, spoon,fork, or all :
Sleeping habits: Does your child nap during the day?
If yes how long?
Describe sleeping needs.(Stuffed animal,blanket,story)

SCHOLASTIC INFORMATION

Current preschool/daycare:
Time attended:
Does your child currently engage in any enrichment programs or organized play groups? Please describe
Is your child potty trained?
Does your child have accidents?
Please indicate any special interests:
Developmental History: Age child began: Sitting
Walking
Talking
What type of behavior management is used at home:

MEDICAL INFORMATION AND MORE

Please check all that apply to your child:
AllergiesPhysical TherapyChronic IllnessAsthmaVision or Hearing DifficultiesPsychological CounselingPhysical RestrictionsTwo Parent FamilyLearning DifferencesSingle Parent FamilyEmotional or Behavioral ConcernsBlended FamilyCurrently Taking MedicationsCustodial ArrangementsSpeech TherapyOccupational TherapyOther
Please note below specific comments for those items checked:
Date of Onset
Please Provide Details
Future Plans
Health Insurance:
Member ID:
Group #:
Member Name:
Physician's name and phone number:

EMERGENCY CARE

Emergency Care - Authorization and Consent Form
I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child (name) However, if I cannot be reached, I hereby authorize Briarwood Child Academy to transport my child to the (hospital name) Hospital and to secure for my child the necessary treatment. I understand the teachers at Briarwood Child Academy are trained in the basics of first aid and I authorize them to give my child first aid when appropriate.
*Parent Signature:
Date:

PICTURE CONSENT

AUTHORIZATION FOR TAKING CHILD’S PICTURE
During the course of various activities pictures may be taken to document the children’s accomplishments. We are requesting your permission to display your child’s picture within the school,Briarwood’s Face book page,or on the school’s website to illustrate these activities.
YESNOWITHIN THE SCHOOL ONLY
FIELD TRIP PERMISSION
The teachers will plan field trips for the children throughout the school year. These field trips will be posted on the Sign In/Out boards, weekly lesson plans and/or a posting in the classroom.

Please choose one permission type:
Blanket. My signature below is the only one needed for my child to attend the class field trips for theschool year.Every Time.I prefer to sign a permission slip every time my child’s class goes on a field trip. I understand that if I do not sign a permission slip once notification has been posted, my child will not be allowed to go on the field trip.

SIGNATURE

By signing below, you verify that all information on this Child Care Application for Enrollment is complete and accurate and that you received a copy of the BCA “Parent hand book.”