Enrollment | Nursery School | Washington University in St. Louis

Date entering Nursery School *

Child's full name *

First/Middle/Last

Child's preferred nickname

Address *

Address

Street Address

Address Line 2

City

State/Province

Zip/Postal

Country

Date of Birth *

Gender *

Female

Male

Child's Class *

Summer Camp

Teddy Bear (AM half day, 2 1/2 to 3 years old)

Teddy Bear (full-day, 2 1/2 and 3 years old)

Bear Cub (AM half day, 3 and 4 year old)

Big Bear (AM half day, 4 and 5 years old)

Bear Cub/Panda Bear (full-day, 3 and 4 years old)

Panda Bear (PM half day, 3 and 4 years old)Panda Bear (PM half day, 3 and 4 years old)

Big Bear/Sun Bear (full-day, 4 and 5 years old)

Sun Bear (PM half day, 4 and 5 years old)Sun Bear (PM half day, 4 and 5 years old)

Parent/Guardian's Name *

First & Last Name

Relationship to Child *

Phone *

Address *

Address

Street Address

Address Line 2

City

State/Province

Zip/Postal

Country

Home Phone *

Cell Phone *

Email *

Employed by *

Employer Address *

Employer Address

Street Address

Address Line 2

City

State/Province

Zip/Postal

Country

Work Phone *

Work Hours *

Parent/Guardian

First & Last Name

Relationship to Child

Home Address

Street Address

Address Line 2

City

State/Province

Zip/Postal

Country

Home Phone

Cell Phone

Employed by

Employer Address

Street Address

Address Line 2

City

State/Province

Zip/Postal

Country

Work Phone *

Work Hours *

Individuals Authorized to have access to Health information other than parent/guardian *

First & Last Name

Relationship to Child *

Address *

Address

Street Address

Address Line 2

City

State/Province

Zip/Postal

Country

Phone *

First Emergency Contact - Local and other than parent or doctor *

First & Last Name

Relationship to Child *

Emergency Contact Address *

Emergency Contact Address

City

State/Province

Zip/Postal

Country

Phone *

Second Emergency Contact - Local and other than parent or doctor *

Relationship to Child *

Address *

Address

City

State/Province

Zip/Postal

Country

Phone *

Individual Authorized to Take Child from Nursery School *

First & Last Name

Relationship to Child *

Address *

Address

City

State/Province

Zip/Postal

Country

Phone *

Individual Authorized to Take Child from Nursery School *

First & Last Name

Relationship to Child *

Address *

Address

City

State/Province

Zip/Postal

Country

Phone *

Comments on Child's Development - allergies, language development, special needs, etc. *

Authorization for Emergency Medical Care

I understand I will be notified at once in case of my child's illness or accident, and I will make arrangements for medical care of my child with the physician or hospital of my choice. If I cannot be reached to make necessary arrangements or in a critical emergency requiring medical care, I hereby authorize Washington University Nursery School to contact my doctor.

Child's Physician *

First & Last Name

Physician Phone Number *

Preferred Hospital *

Hospital Address *

Hospital Address

Street Address

Address Line 2

City

State/Province

Zip/Postal

Country

Health Insurance Carrier *

Person Insured *

First & Last Name

Policy Number *

Carrier Phone Number *

Trip Permission *

I do give consent for my child to take part in field trips or excursions on the WU Campus with this nursery school under proper supervision. If a field trip is planned that is off the WU Campus, information and a permission slip will be sent home for your signature.

I do not give permission for my child to take part in field trip or excursions on the WU Campus.

Media Permission *

I do give permission for my child's image to be used for Washington University Nursery School publication.

I do not give permission for my child's image to be used for Washington University Nursery School publication.

Acknowledgements:
A) The provider and I have agreed on a plan for continuing communication regarding my child's development, behavior, etc.
B) When my child is ill, it is understood and agreed that he/she may not be accepted at school.
C) I have been informed of this facility's policies pertaining to admission, care and discharge of children.
D) I have been informed that a copy of Licensing Rules for Child Day Care Homes/Licensing Rules for Child Care Center in Missouri is available at this facility for review.
E) I understand that, before the first day of attendance by my child, I will provide proof of completed age-appropriate immunizations or exemption from immunizations.
F) I have been notified that I may request notice at initial enrollment or anytime after whether there are children currently enrolled in or attending the facility for whom an immunization exemption has been filed.
G) I have been informed that the Nursery School will not be transporting my child.

Signature *

Type your name

Today's Date *

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