Enroll Your Child Today - Promise Kids Learning Academy

General Information
Thank you for taking an interest in Promise Kids Learning Academy. Don’t delay, join the Promise Kids Learning Academy family today by completing the pre-registration form! It would be our pleasure to serve you.
Child's Name*
First Last
Child's Date of Birth*
Child Lives With:*
- Both parents
- Dad
- Mom
- Guardian
Child’s Home Address: *
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Admission: *
Date of Withdrawal:
Name of Parent or Guardian Completing Form:*
First Last
Address of Parent or Guardian (if different from the child's):
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Parent or Guardian Email*

List telephone numbers below where parents/guardian may be reached while child is in care. *

Parent 1	Parent 2	Guardian's Phone No.	Custody Documents on File Yes/No

Give the name, address, and phone number of the responsible individual to call in case of an emergency if parents/guardian cannot be reached:*

Name	Address	Phone	Relationship

I authorize the child care operation to release my child to leave the child care operation ONLY with the following persons. Please list name and telephone number for each. Children will only be released to a parent or guardian or to a person designated by the parent/guardian after verification of ID. *
- Yes
- Now

Child's Additional Information Section
In the event I cannot be reached to make arrangements for emergency medical care, I authorize the person in charge to take my child to:
Name of Physician:*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Name of Emergency Care Facility:
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
I give consent for the facility to secure any and all necessary emergency medical care for my child. *
Signature – Parent or Legal Guardian:

School Age Children
My child attends the following school:
Name of School:
School Phone Number:
My child has permission to (check all that apply):
- Walk to or from school or home
- Ride a bus
- be released to the care of his/her sibling under 18 years old
Authorized pick up/drop off locations other than the child’s address:

Admission Requirement
If your child does not attend pre-kindergarten or school away from the child care operation, one of the following must be presented when your child is admitted to the child care operation or within one week of admission.
- HEALTH CARE PROFESSIONAL’S STATEMENT: I have examined the above named child within the past year and find that he or she is able to take part in the day care program.
- A signed and dated copy of a health care professional’s statement is attached.
- Medical diagnosis and treatment conflict with the tenets and practices of a recognized religious organization, which I adhere to or am a member of. I have attached a signed and dated affidavit stating this.
- My child has been examined within the past year by a health care professional and is able to participate in the day care program. Within 12 months of admission, I will obtain a health care professional’s signed statement and submit it to the child care operation.
Please check only one option:
Name of Health Care Professional:
First Last
Address of Health Care Professional:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Signature – Parent or Legal Guardian:
Date Signed:

General Information