REAL LIFE NURSERY SCHOOL ENROLLMENT APPLICATION
  
Date of Application:_______________ Date you wish your child to begin:_________
I will drop my child off at:___________  I will pick my child up at: _______________
                                                           (time)                                                                              (time)
PROGRAM
Please check the program you desire for your child along with the days your child will attend.

Little Lambs  2 1/2 - 3 yrs.  Preschool Pals  3 -4 yrs. Kindergarten Readiness  4 -5 yrs.

Kindergarten 5 -6 yrs.        Junior Day Camp (summer program)  4 -6 yrs.

Monday             Tuesday             Wednesday             Thursday             Friday
Child's Name: _______________________________ D.O.B. ___/___/__
Home Address: ______________________  _________  ___________
                                                             No. and Street                          City                            Zip
Home Phone: _______________________________
Mother's Name: ________________________ S.S # _______________
Home Phone: __________________________ D.L.# _______________
Home Address: (if different than child's) ________________________________
Employer's Name: _______________________ Work # ______________
Work Address: _____________________ _________ _________
                                                             No. and Street                                 City                           Zip                     
Father's Name: ________________________ S.S # _______________
Home Phone: __________________________ D.L.# _______________
Home Address: (if different than child's) ________________________________
Employer's Name: _______________________ Work # ______________
Work Address: _____________________ _________ _________
                                                             No. and Street                                 City                           Zip                     

Child lives with:  mother and father  mother    father    other
EMERGENCY CONTACTS:
Name: _____________________ Relationship to child: _______________
Home Phone #: _______________ Work Phone #: __________________
Address: ________________________ ____________ _________
                                                   No. and Street                                 City                        Zip   
Name: _____________________ Relationship to child: _______________
Home Phone #: _______________ Work Phone #: __________________
Address: ________________________ ____________ _________
                                                  No. and Street                                 City                        Zip
Names of person other than parent or legal guardian to whom child may be released
1. _________________________________________________
2. _________________________________________________
3. _________________________________________________
MEDICAL INFORMATION
Name of physician or clinic: _______________________________
Phone #: ______________________________
Address: ________________________ ____________ _________
                                                 No. and Street                                 City                           Zip
Name of dentist or clinic: _________________________________
Phone #: ______________________________
Address: ________________________ ____________ _________
                                                No. and Street                                 City                           Zip
Please list all allergies and any special precautions and/or treatment indicated for these allergies:
________________________________________________________
________________________________________________________
List any medications, food supplements, modified diets currently being administered to child:
________________________________________________________
________________________________________________________
List any chronic physical problems and any history of hospitalization:
________________________________________________________
________________________________________________________
________________________________________________________
EMERGENCY MEDICAL CONSENT
I give permission to Real Life Nursery School licensed by the Department of
Consumer and Industry Services to secure emergency medical and or
emergency surgical treatment for _________ while in care.
                                                   (child's name)
Parent Signature: ____________________________________________
Please list any problem area in your child's life of which the Director should be aware:
______________________________________________________
______________________________________________________
How did you first learn about Real Life Nursery School?
______________________________________________________
______________________________________________________
ENROLLMENT FOR SCHOOL YEAR...SEPTEMBER - JUNE
At the time of enrollment an annual registration fee along with a security
deposit of 2 weeks tuition is required.  This is held as a deposit, and
is applied to the final two weeks tuition when one month's written
notice is given.
Parent's Signature:_____________________  Date: _____________
Director's Signature: ___________________  Date: _____________