Student Enrollment Packet – The Children's Circle – Myers Park United Methodist Church

Student Information

Child's Full Name

First Middle Last

Goes by

Address

Street Address City State ZIP Code

Date of Birth

Gender

Sibling Enrolled

If Yes, Sibling Name and Age

Parent Information

Mom's/Legal Guardian #1 Name

First Last

Mom's/Legal Guardian #1 Cell Phone Number

Mom's/Legal Guardian #1 Work Phone Number

Mom's/Legal Guardian #1 Email Address

Dad's/Legal Guardian #2 Name

First Last

Dad's/Legal Guardian #2 Cell Phone Number

Dad's/Legal Guardian #2 Work Phone Number

Emergency Care Information

Name of Child's Pediatrician

Pediatrician's Phone Number

Hospital Preference

Name of Insurance Plan

ID#

Subscriber's Name (on insurance card)

First Last

Parent/Legal Guardian Consent and Agreement for Emergencies

As parent/legal guardian, I give consent to have my child receive first aid by facility staff, and if necessary, be transported to receive emergency care. I understand that I will be responsible for all charges not covered by insurance. I give consent for an emergency contact person listed on this form to act on my behalf until I am available. I agree to review and update this information whenever a change occurs.

Mom's/Legal Guardian’s Signature #1

Date

Dad's/Legal Guardian’s Signature #2

Date

Medical History

Is your child allergic to anything?* Please Describe

*For confirmed allergies, please complete the Allergy Alert Form and Action Plan - available on the preschool website.

Does your child have any special conditions or medical issues to be aware of?*

*For special conditions or medical issues, please complete the Special Care Plan - available on the preschool website.

Required Forms:
1. Annual Medical Form signed by a physician - due by the 30th day of school for child to maintain enrollment at TCC.
2. Current Immunization Record - due by the 30th day of school for child to maintain enrollment at TCC.

Emergency Contacts

To whom child may be released if legal guardian is unavailable

Emergency Contact #1 Name

First Last

Emergency Contact #1 Phone

Emergency Contact #1 Relationship

Emergency Contact #2 Name

First Last

Emergency Contact #2 Phone

Emergency Contact #2 Relationship

Emergency Contact #3 Name

First Last

Emergency Contact #3 Phone

Emergency Contact #3 Relationship

Permissions

TCC Directory

The Children's Circle Directory, distributed to each family in the fall, is for school family use and may not be reproduced without permission. For the Directory, please select one of the two options below:

I give The Children’s Circle permission to print child’s name, mom’s name, dad’s name, family address, mother’s cell and family's primary email address in The Children’s Circle Directory.
I give The Children’s Circle permission to print only child’s name, mom’s name and dad’s name.

Photography

I agree to the photograph policy.

I do hereby grant the unlimited right to use and/or reproduce photographs,* likenesses or the voice of my child in any legal manner and for the internal or external promotional and informational activities of The Children’s Circle at Myers Park United Methodist Church. I further understand that by signing this release, I waive any and all present, or future compensation rights to the use of the above stated material(s).

Parent's/Legal Guardian #1 Name

First Last

Parent's/Legal Guardian #1 Signature

Date

Instagram Classroom Account

I agree to the Instagram Classroom Account consent.

I give my child's teachers permission to use my child’s photo on the classroom Instagram account, which will be maintained by his or her teachers. The Instagram account is password protected and only for the parents in my child's classroom. This account will serve as a communication tool between the teachers and the parents and will include classroom updates and photos of the children engaged in activities and events.

Class Email List

I agree to the Class Email List consent.

I give my child's teachers permission to share my email address with the other families in the classroom. My email address will only be used for the purpose of classroom communications.

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