Relationship to Child/Parentezco con el niño(a):
Select One Mother Father Stepmother Stepfather Fostermother Fosterfather Grandmother Grandparent Brother Sister Uncle Aunt Other
Primary Contact Name and Last Name /Nombre y Apellido:
Cell-Phone / Telefono Celular
Email/Correo Electronico
Home Address (Street, Number, City, State, Postal Code)/ Dirección de casa (Calle, Numero, Ciudad, Estado, Codigo Postal):
Employer Information / Informacion de Empleador
Work Phone / Telefono de trabajo
Work Address/ Direccion del Trabajo
Relationship to Child/Parentezco con el niño(a):
Select One Mother Father Stepmother Stepfather Fostermother Fosterfather Grandmother Grandparent Brother Sister Uncle Aunt Other
Secondary Contact Name and Last Name /Nombre y Apellido:
Cell-Phone / Telefono Celular
Email/Correo Electronico
Home Address (Street, Number, City, State, Postal Code)/ Dirección de casa (Calle, Numero, Ciudad, Estado, Codigo Postal):
Employer Information / Informacion de Empleador
Work Phone / Telefono de trabajo
Work Address/ Direccion del Trabajo
Monday
Monday
Tuesday
Tuesday
Wednesday
Wednesday
Thursday
Thursday
Friday
Friday
Name / Nombre
Phone/ Telefono
Relationship to Child / Parentezco
Select One Stepmother Stepfather Fostermother Fosterfather Grandmother Grandparent Brother Sister Uncle Aunt Other
Name / Nombre
Phone/ Telefono
Relationship to Child / Parentezco
Select One Stepmother Stepfather Fostermother Fosterfather Grandmother Grandparent Brother Sister Uncle Aunt Other
Name / Nombre
Phone/ Telefono
Relationship to Child/ Parentezco
Select One Stepmother Stepfather Fostermother Fosterfather Grandmother Grandparent Brother Sister Uncle Aunt Other
Child's Name
Child's Last Name
Gender
Select One Female Male
Birthday
Age
Health Insurance / Seguro Medico:
Policy Number/Numero de Poliza:
Upload Medical Card
Name of Child’s Physician/Nombre del Doctor:
Physician’s Telephone Number/Telefono del doctor:
Physician’s Address/Direccion del Doctor:
Allergies (Including Medication Reaction)/Alergias (Incluya medicamentos)
Special Conditions or Dietary Restrictions/ Condiciones Especiales o Restricciones Alimenticias:
Additional Information on Particular Needs of Child / Informacion Adicional en Necesidades Particulares del Nino:
Custody of Child / Custodia del Niño
Select One Both Parents Mother Father Other
Add Comments / Añadir Comentarios:
Copy of Custody Order/ Copia de Custodia
Select your child’s elementary school:
Select One McNichols Plaza Elementary John G. Whittier Elementary Other (Not transportation Provided)
Grade
Select One Kindergarten First Grade Second Grade Third Grade Fourth Grade Fifth Grade Sixth Grade
Transportations Need
Select One I do NOT wish for WellKind School for Early Learners to transport to elementary school. Only transportation TO elementary school. Only transportation FROM elementary school. Transportation TO AND FROM elementary school.
Obtaining Medical Care - By signing this you are giving us permission to call 911 if needed. / Obtener Atencion Medica de Emergencia - Al Aceptar, nos autoriza llamar al 911 en caso de emergencia.
I Accept / Acepto
Admin First Aid - By signing you are giving us permission to provide minor first aid help for small cuts, bumps, etc. / Administrar Primeros Auxilios - Al Aceptar nos autoriza, administrar primeros auxilios por cortadas, raspaduras, golpes y otros accidentes menores.
I Accept / Acepto
Walks and Trips - By signing you are allowing your child to go for outdoor walks. / Caminatas y Excursiones - Al Aceptar autoriza que su hijo (a) vaya en caminatas y/o excursiones.
I Accept / Acepto
Transportation by the Facility. By signing you are allowing us to transport your child to elementary school, on a field trip, or in case of an emergency. / Transportacion por WellKind School - Al Aceptar autoriza que su hijo (a) sea transportado a la Escuela Primaria, en Excursiones o en caso de Emergencia.
I Accept / Acepto
The use of all media such as the display, distribution, publication, transmission, or otherwise use of photographs, images, and/or video taken of above mentioned child can be use in materials that include, but may not be limited to printed materials such as brochures and newsletters, videos, and digital images such as those on the WellKind School for Early Learners website. Child’s personal information will not be used in conjunction with any video or digital images. El uso de media incluyen la demostración, distribución, publicación, transmisión o el uso de fotografías, imágenes y / o videos tomados del niño mencionado puede ser para uso en materiales que incluyen, pero no se limitan a materiales impresos como folletos y boletines informativos, videos e imágenes digitales como los que se encuentran en nuestro sitio web. La información personal de su hijo(a) no se utilizará junto con ningún video o imagen digital.
Select One Deny permission to use my image or my child’s image/Negar permiso de utilizar la imagen de mi hijo(a). Grant permission to use my child’s image/Autorizar permiso de utilizar la imagen de mi hijo (a).
WellKind School for Early Learners applies a sunscreen product that is broad spectrum with SPF 15 or higher to children, when they go outside during the months of May through October and between the day time hours of 10 a.m. and 4 p.m. Sunscreen may be applied to exposed skin, including but not limited to the face (except eyelids), tops of ears, nose, bare shoulders, arms and legs. Please check below all applicable information regarding permissions and use of sunscreen
Select One Staff may use the sunscreen of the program’s choice on my child / Pueden aplicar protector Solar que el programa elija. I will provide own sunscreen / Yo proveere el protector solar. Do not apply any sunscreen/No aplicar proteccion solar.
Child's Name
Child's Last Name
Gender
Select One Female Male
Birthday
Age
Health Insurance / Seguro Medico:
Policy Number/Numero de Poliza:
Upload Medical Card
Name of Child’s Physician/Nombre del Doctor:
Physician’s Telephone Number/Telefono del doctor:
Physician’s Address/Direccion del Doctor:
Allergies (Including Medication Reaction)/Alergias (Incluya medicamentos)
Special Conditions or Dietary Restrictions/ Condiciones Especiales o Restricciones Alimenticias:
Additional Information on Particular Needs of Child / Informacion Adicional en Necesidades Particulares del Nino:
Custody of Child / Custodia del Niño
Select One Both Parents Mother Father Other
Add Comments / Añadir Comentarios:
Copy of Custody Order/ Copia de Custodia
Select your child’s elementary school:
Select One McNichols Plaza Elementary John G. Whittier Elementary Other (Not transportation Provided)
Grade
Select One Kindergarten First Grade Second Grade Third Grade Fourth Grade Fifth Grade Sixth Grade
Transportations Need
Select One I do NOT wish for WellKind School for Early Learners to transport to elementary school. Only transportation TO elementary school. Only transportation FROM elementary school. Transportation TO AND FROM elementary school.
Obtaining Medical Care - By signing this you are giving us permission to call 911 if needed. / Obtener Atencion Medica de Emergencia - Al Aceptar, nos autoriza llamar al 911 en caso de emergencia.
I Accept / Acepto
Admin First Aid - By signing you are giving us permission to provide minor first aid help for small cuts, bumps, etc. / Administrar Primeros Auxilios - Al Aceptar nos autoriza, administrar primeros auxilios por cortadas, raspaduras, golpes y otros accidentes menores.
I Accept / Acepto
Walks and Trips - By signing you are allowing your child to go for outdoor walks. / Caminatas y Excursiones - Al Aceptar autoriza que su hijo (a) vaya en caminatas y/o excursiones.
I Accept / Acepto
Transportation by the Facility. By signing you are allowing us to transport your child to elementary school, on a field trip, or in case of an emergency. / Transportacion por WellKind School - Al Aceptar autoriza que su hijo (a) sea transportado a la Escuela Primaria, en Excursiones o en caso de Emergencia.
I Accept / Acepto
The use of all media such as the display, distribution, publication, transmission, or otherwise use of photographs, images, and/or video taken of above mentioned child can be use in materials that include, but may not be limited to printed materials such as brochures and newsletters, videos, and digital images such as those on the WellKind School for Early Learners website. Child’s personal information will not be used in conjunction with any video or digital images. El uso de media incluyen la demostración, distribución, publicación, transmisión o el uso de fotografías, imágenes y / o videos tomados del niño mencionado puede ser para uso en materiales que incluyen, pero no se limitan a materiales impresos como folletos y boletines informativos, videos e imágenes digitales como los que se encuentran en nuestro sitio web. La información personal de su hijo(a) no se utilizará junto con ningún video o imagen digital.
Select One Deny permission to use my image or my child’s image/Negar permiso de utilizar la imagen de mi hijo(a). Grant permission to use my child’s image/Autorizar permiso de utilizar la imagen de mi hijo (a).
WellKind School for Early Learners applies a sunscreen product that is broad spectrum with SPF 15 or higher to children, when they go outside during the months of May through October and between the day time hours of 10 a.m. and 4 p.m. Sunscreen may be applied to exposed skin, including but not limited to the face (except eyelids), tops of ears, nose, bare shoulders, arms and legs. Please check below all applicable information regarding permissions and use of sunscreen
Select One Staff may use the sunscreen of the program’s choice on my child / Pueden aplicar protector Solar que el programa elija. I will provide own sunscreen / Yo proveere el protector solar. Do not apply any sunscreen/No aplicar proteccion solar.
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