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Preschool Registration

Child's First Name
Last Name
Hebrew Name
Nickname
Birth Date
MonthDayYear
Age in September 2018*
Gender

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone
Area CodePhone Number
PARENT/GUARDIAN INFORMATION
Parent's Name*
NameHebrew Name
Jewish*
YesNo

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Cell Phone
Area CodePhone Number
Work Phone
Area CodePhone Number
Occupation and Place of Employment*
E-mail
Parent's Name*
NameHebrew Name
Jewish*
YesNo

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Cell Phone
Area CodePhone Number
Work Phone
Area CodePhone Number
Occupation and Place of Employment*
E-mail
How did you hear about Chai Tots Preschool?*
Why do you want your child to attend Chai Tots Preschool?
What days/hours are you interested in?
Morning hours: 9:00 AM -12:30 PM
Full day hours: 9:00 AM - 3:00 PM
Please not that there will be a fee if there will be any changes made to the schedule selected above. An additional $75 will be charged to anyone who changes their child's schedule before the first week of school. A $150 fee will be charged after the first week of school.
Changes will be made upon the school's discretion.
Are you interested in any specific days of the week, or are you flexible? Please specify.
We cannot guarantee your preferred days. Remember, we can best provide for those who are flexible.
Do you require early dropoff or late pickup?
Early dropoffLate pickup
Please check your site preference*
Park SlopeWindsor TerraceProspect Heights
Are you flexible? Please specify.
PICKUP
Person authorized to pick up child
Person who may not pick up child
I have reviewed the guidlines and I hereby register my child for the 2018-2019 school year. I also understand that once my child is accepted and contracts are signed, there are no refunds under any circumstances.
Signature of Parent*
Date
CHILD'S INFORMATION
Does the child have any previous childcare/preschool experience?
Are there any physical disabilities or medical conditions that require accommodations or services? Please explain.
Does the child have any allergies?*
Is there special food or eating instructions?
Is there any specific napping or sleeping instructions?
what words does the child use to indicate that he/she needs the toilet?
Does the child have any bowel or bladder irregularities?
Is the child right or left handed?
Is there any additional information, such as child's communication, discipline, or family circumstances that you feel we should know about?
FAMILY INFORMATION
Sibling(s) Please indicate ages and if they live with the child being registered:
Please list any other persons livings with the child and their relationship to the child:
Are you affiliated with any synagogue or religious organization?
If yes, please specify
EMERGENCY CONTACTS
Please indicate telephone numbers where you and another authorized person can be contacted in case of emergency:
Parent's Name
Phone Number
Parent's Name
Phone Number
Additional authorized person
Relationship to child
Phone
Address
CHILD'S DOCTOR
Child's name
Child's physician
Phone
Address
Child's Dentist
Phone
Address
EMERGENCY CARE
In case of emergency, I authorize the staff to provide any medical care or first aid deemed necessary for my child.
In case of an emergency in which I cannot be reached, the physician listed above and the local hospital are hereby authorized to provide any emergency care deemed necessary for my child.
In case of emergency, I hereby authorize the transfer of my child's records to the local hospital.
I hereby agree to the above and give my permission to care for my child in case of emergency, including medical care or first aid; transfer of care to my child's physician or local hospital and health records transfer.
Signature of Parent*
Date
Registration Deposit (plus 3% cc processing fee)*
$206

Payment

Credit Card

Credit Card Type
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Should be Empty:

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Preschool Registration

PARENT/GUARDIAN INFORMATION

What days/hours are you interested in?

PICKUP

CHILD'S INFORMATION

FAMILY INFORMATION

EMERGENCY CONTACTS

CHILD'S DOCTOR

EMERGENCY CARE

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