Online Student Enrollment Application Online Student Enrollment ApplicationOnline Student Enrollment Application Enrollment FormChoose the location of the center where the child is being enrolled*BUFFALO CENTERCEREDO CENTERCEREDO PRESCHOOLHUNTINGTON CENTERKENOVA CENTERLAVALETTE CENTERWESTMORELAND CENTERWESTMORELAND TEEN CENTEREARLY EDUCATION CENTER of WESTMORELANDDate of Admission Month Day Year Date of Discharge Month Day Year Child's Full Name* First Middle Last Name Child Goes By* First Child's Date of Birth* Month Day Year Child's Birthplace* City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Child's Home Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Child's Home Phone*Which school is your child currently attending? School PhoneWVEIS # Scheduled Days & Hours for Care: Parent or Guardian InformationGuardian 1's Full Name* First Last Guardian's PhoneOkay to Text? Yes No Guardian's Email Address Guardian's Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Occupation and Place of Employment Work PhoneSocial Security Number Guardian 2's Full Name* First Last Guardian's PhoneOkay to Text? Yes No Guardian's Email Address Guardian's Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Occupation and Place of Employment Work PhoneSocial Security Number How did You Hear About Us? Facebook Friend or relative Television Website Family InformationBrothers and/or sisters (Please indicate ages and whether they live with the child) Please list any other persons living with the child and their relationship (if any) to child Personal HistoryIs you child right or left handed Right handed Left Handed Does your child participate in any other group setting or preschool program? (Please include Speech, Physical therapist, ect.): If so, where and when: List any and all food or drug allergies Does child have any bowel or bladder irregularities? Any additional information such as child's communication methods? HealthAny chronic illness or hospitalization?; Any disabilities? Any regular medication? Also, side effects of medication? A health assessment and immunization record signed by the child's licensed health provider must be providedEatingFood Allergies How does child eat Toilet HabitsDoes child indicate bathroom needs Words for urination? Bowel movement? Sleeping HabitsDoes child take nap? Yes No If yes, what hours of the day and how long? What helps the child to go to sleep? What time does your child go to bed in the evening and what time does your child wake-up? Social RelationshipsOther play groups By nature , is child (mark all that apply): Friendly Aggressive Shy Withdrawn How does child relate to stranger? Does child play well alone: Yes No Favorite toy: Frightened by (mark all that apply): Animals Rowdy children Loud noises Darkness Storms Other How do you comfort your child? Does the family receive any support from agencies in the community? Is the family receiving support from early intervention? Field Trip Permission Slip and Transportation PolicesMy child has permission to attend and to be transported by Playmates Preschool and Child Development Centers, Inc. paid employees and volunteer staff to field trips. Type child name in the box below. Parents please discuss with your child or children the importance of field trip rules. * Seat Belts (children and adults. *No standing or yelling on vans (children and adults) *No eating or drinking on vans (May cause choking) (children and adults) *Always use our best manners on van and places we visit ( children and adults) *For many years we have had a reputation for having very well-behaved children when we visit places. We at Playmates feel that with our staff and parents working together, we will continue to have safe, fun, and wonderful trips. Thank you for being an involved parent.Parent's Signature, type your name. Sunscreen PermissionI give permission for Playmates to apply sunscreen (SPF 15 or higher) any time my child may be exposed for a period in the sun.* Child's Name Parent's Signature, type your name. Todays Date Use of Insect Repellents PermissionIn case of emergency when public health authorities recommend the use of insect repellants due to high risk of insect-borne disease, only repellents containing Deet will be used, and these are applied only on older than two months. I give consent for staff to apply insect repellent once per day.* Child's Name Parent's Signature, type your name. Todays Date Photograph, Audio, and Video Tape PermissionI give Playmates Preschool & and Child Development Centers, Inc. permission to photograph, audio, or Videotape my child during special activities or for news stories and advertising purposes. I also authorize the videotaping of my child as part of a routine security procedure.Child's Name Parent's Signature, type your name. Enrollment AgreementI hereby enroll my child in Playmates Preschool & and Child Development Centers, Inc.for the days and hours listed above. I have met with center staff. They have explained all center policies including behavior management and reporting of abuse and neglect and provided me with a copy of those polices.Child's Name Parent's Signature, type your name.