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                                                                   Revised May 2010     
              EAGLE ADVENTIST CHRISTIAN SCHOOL & PRESCHOOL
            (Elementary, Preschool, Kindergarten, Child Care, Before & After-school Care)
                                    538 West State Street, Eagle, ID
 Phone 208-938-0093, Preschool & FAX 939-5544    Website:   eagleadventistchristian.com

Students Full Legal Name_____________________________________________________________

                                       Last Name            First                       Middle                   SS#

Birth date __________________         Sex:      Male  Female     Nickname _________

Age ____   _____ Place of Birth_______Family Church Preference _______________
        Years    Months 

For Seventh-day Adventist Students only:     Which church are you a member of?

Father ___________________________Yr. baptised_______

Mother __________________________Yr. baptisted_______

Child ____________________________Yr. baptised ______ 

I give permission to have address & phone in the school directory - yes___no___ (initial please) 

Parent/Guardian #1______________________________________________________________

   (Primary Address)  Last Name                 First                   Middle            S.S.# 

Address #1  ___________________________________________________________________

                          Street                     City/State              Zip                               Billing E-mail Address

Phone  ________________________________________________________________________

                      Home                        Business                               Cell                                 FAX      

Business #1 ____________________________________________________________________

                                    Occupation                                           Employed By 

Parent/Guardian #2_______________________________________________________________

                       Last Name                         First                  Middle                   S.S.#

Address #2   _________________________________________________________________

                          Street                     City/State              Zip                         Alternate E-mail Address

Phone   #2 __________________________________________________________________

                           Home                         Business                  Cell                                  FAX

Business #2 _________________________________________________________________

                           Occupation                                           Employed By 

Emergency Call           
1. ________________________________________________________________________

                                    
2. _________________________________________________________________________

    Person other than parent          Home Number                 Cell                Work 

Authorized escorts in case parent cannot be reached.

 


 

 

I would like to contract for the following services:             Requested school-start date for child:___________

    

Elementary School -           Grade entering _______________

            Last school attended __________________Grade last year______Teacher___________________

1.         Pre/Kindergarten - ½ day am       _____             (5 yr. old by Oct. 1) 

                        Pre/Kindergarten - full day           _____                  

 

2.         Kindergarten - ½ day am         _____             (5 yr. old by Sept. 1) 

Kindergarten - full day             _____

 

3.         Pre-First (full day)                   _____             (6 yr. old by Oct. 1)

          4.        Pm Kindergarten (12-3:30pm) _____             (enrolled at public am Kindergarten)

1. Preschool Only: (Half-day, 8:30 a.m. to 12:30 noon)                    M___ T___ W___ Th___ F____

2. Preschool and Child Care (Full-day, 7:00 a.m. to 6:00 p.m.*)       M___ T___ W___ Th___ F___

 

Child care (all ages)     7am - 8:30am, Noon - 6pm or 3:30pm - 6pm

 

 

1.   Before school care: M ____ T ____ W ____ Th ____ F ____ As Needed _____ (7am-8:30am)

2.   After school care:   M_____ T_____ W____ Th_____F____ As Needed _____ (3:30pm-6pm)

            3.   Summer care:          M_____T_____W_____Th_____F_____As Needed _____ 

 

 

I found out about this school through:   TV _____ Radio _____  Yellow pages _____ Magazine _____

            (Please check all that apply)                          Pamphlet ____ Mail ____ Friend (Name)_______________________

 

Idaho law (Idaho Code 18-8327 and 18-8414) prohibits the Eagle Adventist Christian School & Child-Care Center, from employing, using as volunteers, or allowing any person on the premises who is registered or required to be registered under the sex offender mandatory registration requirements of Idaho law. The only exception to this prohibition is that such person shall be allowed to drop off and pick up that person's own child or children. If you are presently registered or required to be registered under Idaho sex offender mandatory registration requirements, you must adhere to these restrictions and you have a duty to notify us so that we can assist you in meeting these restrictions. By signing below, you verify that you are not subject to such registration requirements. If you are subject to such registration requirements, please note this on this form prior to signing.

________________________    ________                ________________________     ________

Signature of Father/Guardian                Date                         Signature of Mother/Guardian    Date

__________________________________                       ________________________

Signature of Director/Principal                                                        Date accepted

We, the under signed parents or guardian of __________________________________, a minor,

do hereby consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment

and hospital service that may be rendered to said minor under the general or special instructions of

___________________________________, M. D., (phone # ______________) or any physician the

school or organization may call, whether such diagnosis or treatment is rendered at the office of said

physician or at a licensed hospital. It is understood that reasonable effort will be made to contact the

doctor listed above before any other physician is called by the school or other organization.

It is further understood that this consent is given in advance of any specific diagnosis or treatment

which might be required and is given to authorize EAGLE ADVENTIST CHRISTIAN SCHOOL,

PRESCHOOL AND CHILD CARE CENTER or the physician to exercise the best judgment as

to the requirements of such diagnosis or treatment.

 

This consent shall remain in continuous effect until revoked in writing and delivered to the physician

named above and to the school or organization entrusted with the custody of said minor.

 

We hereby authorize any hospital, physician, or other person who has attended or examined the minor

to furnish to CHRISTIAN EDUCATORS INSURANCE TRUST, through it's representative, at the IDAHO CONFERENCE OF SEVENTH-DAY ADVENTISTS any and all information with respect to any illness,

medical history, consultation, prescriptions or treatment, and copies of all hospital or medical records. 

This release authority applies to any information governed by the Health Insurance Portability and

Accountability Act of 1996 (HIPPA), 42 U.S.C. 1320d and 45 CFR 160 through 164. A Photostat copy

of this authorization shall be considered as effective and valid as the original.

 

MY CHILD IS ALLERGIC TO THE FOLLOWING FOODS / MEDICATIONS: ________________________

_______________________________________                  Date ____________________________

Signature of Father                                                               

_______________________________________                  Date____________________________

Signature of Mother                                                            

_______________________________________                  Date ____________________________

Signature of Legal Guardian                                               

_______________________________________                  Date ____________________________

Witness

Phone #s where we can be reached ________________________________________________________

Medical insurance company_______________________________________Phone__________________

Address______________________________________________________Group number____________

Name of insured_____________________________    Insured ID# __________________________

I verify that the information listed is complete an accurate. 

______________________________                        _________________

Signature of parent/guardian                                          Date

Marital Status: Married ( ) Separated ( ) Divorced ( ) Remarried ( )

If remarried name of step-parent__________________ 

Custody/visiting arrangements:__________________________________________________________________

What are your child's siblings names and ages. _____________________________________________________

What health problems has your child had in the past? __________________________________________

What health problems does your child have now? _____________________________________________
How Severe? __________________________________________________________________________

Does your child take any medicine regularly? If so, why? ______________________________________

How your child ever been hospitalized? If so, when and why?____________________________________

Has a disability been diagnosed (such as cerebral palsy, seizure disorder, developmental delay?) _________

Do you have any other concerns about your child's health? _______________________________________

Development (compared to other children this age)

Does your child have any problems with talking or making sounds? Please explain. ___________________

Does your child have any problems with walking, running, or moving? Please explain. _________________

Does your child have any problems hearing? Please explain. ______________________________________

Does your child have any problems using her or his hands (such as with puzzles, drawing, small building pieces?) Please explain. ___________________________________________________________________________

Does your child have any problems with mood or behavior? Please explain. ___________________________

Is child right or left handed?_____ Child’s normal bed time?_____Does child sleep well?______Take a nap?____

Favorite indoor activities?__________________________________Outdoor?______________________

How would you best describe your child’s personality?_________________________________________

What is your child's typical eating pattern? _______________________________________________________
*Any dietary restrictions?_______________________________________

What foods does your child             like? _____________________ dislike? ________________________

How well does your child use table utensils (cup, fork, spoon)? ________________________________________

How does your child indicate bathroom needs? _____________________________________________________

Word(s) for urination: ___________ Word(s) for bowel movements _________ 

Special words for body parts: ___________________________________________________________________

What are your child's regular bladder and bowel patterns? ____________________________________________

What ages are your child's most frequent playmates? _________________________________________________

Is your child (circle all that apply) friendly? aggressive? shy? withdrawn? ________________________________

Does your child need extra time/preparation to change from one activity to another? ________________________

Does your child play well alone? ________________ What is your child's favorite toy? _____________________

Is your child frightened by (circle all that apply) animals? rough children? loud noises? new experiences? 
the dark? storms? anything else? ___________________________________________________________________

Who does most of the disciplining? __________________ What works best when you discipline your child? ___________________________________________________________________________________________

What is child’s usual reaction?____________________________________________________________

How do you comfort your child? ___________________________________________________________

Does your child use a special comforting item (such as a blanket, stuffed animal, doll)? ________________

With which adults does your child have frequent contact? _________________________________________

EAGLE ADVENTIST CHRISTIAN CENTER

538 WEST STATE STREET

EAGLE, IDAHO 83616

208-939-5544

 

PERMISSION SLIP

 

I HEREBY GRANT PERMISSION FOR MY CHILD TO USE ALL OF THE PLAY EQUIPMENT
AND PARTICIPATE IN ALL OF THE ACTIVITIES OF THE SCHOOL.

 

I HEREBY GRANT PERMISSION FOR MY CHILD TO LEAVE THE SCHOOL PREMISES 
UNDER THE SUPERVISION OF A STAFF MEMBER FOR NEIGHBORHOOD WALKS 
OR FOR FIELD TRIPS.

 

I HEREBY GRANT PERMISSION FOR MY CHILD TO BE INCLUDED IN VALUATIONS
AND PICTURES CONNECTED WITH THE SCHOOL PROGRAM.

 

I HEREBY GRANT PERMISSION FOR THE DIRECTOR, OR ACTING DIRECTOR, 
TO TAKE WHATEVER STEPS NECESSARY TO OBTAIN MEDICAL CARE IF WARRANTED. THESE STEPS MAY INCLUDE BUT ARE NOT LIMITED 
TO THE FOLLOWING:

 

A. ATTEMPT TO CONTACT THE PARENT/GUARDIAN.

B. ATTEMPT TO CONTACT YOU THROUGH ANY OF THE PRESONS LISTED ON THE

REGISTRATION FORM.

C. IF WE ARE UNABLE TO CONTACT YOU OR THE PERSONS LISTED, WE WILL DO ANY OR  
            ALL OF THE FOLLOWING:

                        1. CALL 911

                        2. HAVE CHILD TAKEN TO AN EMERGENCY HOSPITAL IN THE COMPANY OF  
                              A STAFF MEMBER.

D. ANY EXPENSES INCURRED UNDER "C" ABOVE, WILL BE THE RESPONSIBILITY OF THE

            CHILD'S FAMILY.

E. EAGLE ADVENTIST CHRISTIAN CENTER WILL NOT BE RESPONSIBLE FOR ANYTHING   
             THAT MAY HAPPEN AS A RESULT OF FALSE INFORMATION GIVEN AT THE TIME 
             OF  ENROLLMENT.

F. THE EAGLE ADVENTIST CHRISTIAN CENTER WILL NOT BE RESPONSIBLE FOR A CHILD 
             THAT HAS NOT BEEN PROPERLY CHECKED IN ON ARRIVAL EACH DAY.

 

________________________________________                ______________________

Signature of Mother/Legal Guardian                                              Date

 

________________________________________                ______________________

Signature of Father/Legal Guardian                                                Date

 

________________________________________                ______________________

Signature of Director                                                                      Date

 

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