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Enrollment Form
Child's Name
*
First
Middle
Last
Birth Date
*
Month
Day
Year
Nickname(s)
Gender
*
Male
Female
Guardian Information
Guardian 1
Name
*
First
Last
Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone
*
Cell Phone
Work Phone
Employer Name
*
Email Address
*
Last 4 digits of your SSN
*
Guardian 2
Name
*
First
Last
Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone
*
Cell Phone
Work Phone
Employer Name
*
Email Address
*
Last 4 digits of your SSN
*
Emergency Information
Licensing requires each family to have 2 emergency contacts who live within one hour drive of the school. The 2 contacts may not reside at the same address.
Emergency Contact 1
Name
*
First
Last
Relationship
*
Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone 1
*
Phone 2
Emergency Contact 2
Name
*
First
Last
Relationship
*
Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone 1
*
Phone 2
Medical Information
Dentist Name
*
Dentist Phone
*
Doctor Name
*
Doctor Phone
*
Health Insurance
Company Name
*
Primary Card Holder Name
*
Policy or Group #
*
ID #
*
Does your child have any known allergies that may require medical attention or medication?
*
Yes
No
Please comment on any other relevant medical information, special needs or developmental delays that your child has.
Does your child have any dietary restrictions aside from food allergies. If yes, please describe.
Meal Plan Option
*
I am accepting the meal plan for my child.
I am declining the optional meal plan; my child will bring his/her own lunch.
Permissions
EMERGENCY MEDICAL AUTHORIZATION
We will make every reasonable effort to contact you in the event of a medical emergency. If you cannot be located immediately, your signature below authorizes The Cedarhouse School to obtain immediate medical and/or dental care for your child, including but not limited to; transporting your child to the nearest hospital, the performance of diagnostic tests or surgery, and the administration of pharmaceuticals. Further, you agree to be responsible for payment of all expenses incurred in seeking medical treatment for your child.
Guardian Name
First
Last
Date
Month
Day
Year
PHOTO/VIDEO RELEASE
Pursuant to the photo release policy outlined in The Cedarhouse School Parent Manual, I hereby give permission for images of my child, captured during regular school activities and events, through video, photo and digital camera to be used solely for the purposes of Cedarhouse marketing and promotional materials and publications, and waive any rights of compensation or ownership thereto.
Guardian Name
First
Last
Date
Month
Day
Year
FIELD TRIP PERMISSION (School Age Summer Camp Only)
I understand that The Cedarhouse School has scheduled periodic off-site activities (“field trips”) as a part of its summer camp program. I give permission for my child to participate in these activities, which include transportation on Cedarhouse activity buses. I understand that the Cedarhouse will take reasonable precautions in the interest of safety however, neither The Cedarhouse School nor any employee, nor any sponsor of any trip or activity will be held liable for any accident, injury or illness that might occur to my child while on such trip or while participating in such activity. I hereby expressly release the Cedarhouse, its employees and all such sponsors of such trip or activity from any and all liability for any accident, injury or illness which may be sustained by such student while on such trip or while participating in such activity.
Guardian Name
First
Last
Date
Month
Day
Year
SWIMMING PERMISSION (School Age Summer Camp Only)
I understand that The Cedarhouse School has scheduled periodic swimming trips to local recreation centers as a part of its summer camp program. I give permission for my child to participate in these swimming trips, which include transportation on Cedarhouse activity buses. I understand that the Cedarhouse will take reasonable precautions in the interest of safety, including submitting my child to a swim test to categorize his/her abilities. However, neither the Cedarhouse School nor any employee, nor any sponsor of any swimming trip will be held liable for any accident, injury or illness that might occur to my child while on a swimming trip. I hereby expressly release the Cedarhouse, its employees and all such sponsors from any and all liability for any accident, injury or illness which may be sustained by my child while on such trip.
Guardian Name
First
Last
Date
Month
Day
Year