KIRKLAND PRESCHOOL’S SUMMER ADVENTURES 2011

Child’s Name ___________________________________________________________________

Sessions Requested:

_______ Session 1 6/28 – 7/8 ($100 deposit due with registration + $210* tuition due 6/28)

(note: Session 1 runs Tues-Fri; Sessions 2,3 &4 run Mon-Thurs)

_______ Session 2 7/11 – 7/21 ($100 deposit due with registration + $210* tuition due 7/11)

_______ Session 3 7/25 – 8/4 ($100 deposit due with registration + $210* tuition due 7/25)

_______ Session 4 8/8 – 8/18 ($100 deposit due with registration + $210* tuition due 8/8)

* please note – additional siblings’ total tuition is $290, each additional child, each session

Gender_______ Age____ Birthdate__________ Living with both parents?_______ or _________

Parent’s Name__________________________________________________________________

Preferred phone________________________ Alternate phone______________________

Address (include city, zip)____________________________________________________

Parent’s Name___________________________________________________________________

Preferred phone________________________ Alternate phone_______________________

Address (include city, zip)_____________________________________________________

Other caregiver’s name & phone number (child care provider who would be bringing child to or from school on
a regular basis) ______________________________________________________________________

In case of emergency, when unable to contact parents, this person can be contacted and is authorized to release
child from school:

Name_______________________________ Phone_______________ Relationship_____________

Allergies, sunscreen restrictions or food restrictions ________________________________________

______________________ ___________________________________________________________

If you have completed an application for this child for our Sept.-June school year, please note any updated information
and sign & date ________________________________________________________________________________

^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^

If you have not already given us this information, please complete the rest of this application:

Doctor/Practitioner_____________________________________ Phone_______________________

Names of other children in family: Age Gender

_________________________________________________________________________________

_________________________________________________________________________________

Vision, hearing, speech or learning concerns______________________________________________

__________________________________________________________________________________

Please make sure your child’s immunizations are current. Most current dates for:

D.P.T.___________ Polio__________ Measles_________ Mumps__________ Rubella__________ HIB__________

Hepatitis B__________ “Chicken Pox”__________

If your child is not immunized, please tell us why_______________________________________________

PERMISSION FOR NEIGHBORHOOD WALKS:

_____________________________ has my permission to walk in a supervised group to neighborhood
destinations such as Turtle Park. The teachers will post a notice on the school entrance door and will
carry all emergency forms, the first aid kit, a cell phone, etc.

Parent’s signature Date

CONSENT FOR MEDICAL CARE AND TREATMENT:

I, _______________________________, am the parent or guardian having legal custody of the child
named on the front of this form. I authorize all medical, diagnostic, surgical, and hospital care or
procedures, as well as emergency transportation, which may be performed or prescribed for my child
by a licensed physician or hospital or emergency medical personnel, when efforts to contact me are
unsuccessful and when deemed immediately necessary or advisable by the physician to safeguard my
child’s health. I waive my right of informed consent to such treatment.

__________________________________________________________________________________

Parent’s Signature Date

Please designate: ______ Natural or adoptive parent ______ Legal Guardian

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Please submit application with $100 deposit per session to:

Kirkland Preschool, 802 – 2^nd St., Kirkland, WA. 98033