SUPER KIDS’ PLACE (SKP) ENROLLMENT FORM
1. Child's Name
____________________________________________________ Date of Birth_____________
Sex __
2. Parent’s Status:
a. Single ___ Married ____ Divorced ___ Separated ___
b. Is there a separation or divorce custody issue of which the staff should be aware?
_____________________________________________________________________________________
________________________________________________
3. Child’s Information:
a. Other siblings in the home
Name ________________________ Date of Birth____________ Enrolled in Program? _________
b. Does your child have any allergies or food dislikes?
_____________________________________________________________________________________
_____________________________________________________
c. How does your child get along with other children?
_____________________________________________________________________________________
_____________________________________________________
d. Are there any physical, emotional, or disability issues your child is being treated for?
_____________________________________________________________________________________
_____________________________________________________
e. Does your child take any daily prescribed medications? If so, what and when?
_____________________________________________________________________________________
_____________________________________________________
f. Does your child have special needs or an IFSP/IEP that we should be aware of? If so, would you like to provide us all or part of the IFSP/IEP?
________________________________________________________________________________________
g. Is there any other information about your child you believe will be helpful to the staff in understanding?
and caring for your child?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________
Mail to school of enrollment. Address found on contact page.
1. Child's Name
____________________________________________________ Date of Birth_____________
Sex __
2. Parent’s Status:
a. Single ___ Married ____ Divorced ___ Separated ___
b. Is there a separation or divorce custody issue of which the staff should be aware?
_____________________________________________________________________________________
________________________________________________
3. Child’s Information:
a. Other siblings in the home
Name ________________________ Date of Birth____________ Enrolled in Program? _________
b. Does your child have any allergies or food dislikes?
_____________________________________________________________________________________
_____________________________________________________
c. How does your child get along with other children?
_____________________________________________________________________________________
_____________________________________________________
d. Are there any physical, emotional, or disability issues your child is being treated for?
_____________________________________________________________________________________
_____________________________________________________
e. Does your child take any daily prescribed medications? If so, what and when?
_____________________________________________________________________________________
_____________________________________________________
f. Does your child have special needs or an IFSP/IEP that we should be aware of? If so, would you like to provide us all or part of the IFSP/IEP?
________________________________________________________________________________________
g. Is there any other information about your child you believe will be helpful to the staff in understanding?
and caring for your child?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________
Mail to school of enrollment. Address found on contact page.