The Learning Tree Enrollment Application

Please submit the below application to complete your child’s enrollment. If you are enrolling siblings, you will need to complete an application for each individual child.
It is the responsibility of the parent and guardian to file updates and changes as the occur at least annually. Thank you.

Child's Name

First Name

Last Name

Child's Date of Birth

YYYY

Child's Physical Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child lives with:

Please list the names of the person's living in the same primary household as the child.

Parent 1/Guardian Name

First Name

Last Name

Parent Email 1

Parent Address 1

If different from the child's

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent 2/Guardian Name

First Name

Last Name

Parent 2 Email

Parent Address 2

If different from the child's

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contacts

Children will be released only to the parents/guardians listed above. The child can also be released to the following individuals, as authorized by the person who signs this application. In the event of an emergency, if the parents/guardians cannot be reached, the facility has permission to contact the following individuals.

Healthcare Needs

For any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services, a medical action plan will need to be submitted to the school. The medical action plan must be completed by the child's parent or health care professional. Will you be submitting a medical action plan?

Yes

Allergies

List any allergies and the symptoms and type of response required for allergic reactions.

Symptoms & Response

List any health care needs or concerns, symptoms of and type of response for these health care needs or concerns

Behavior

List any particular fears or unique behavior characteristics the child has that you feel we should be aware of.

Medication

List any types of medication taken for health care needs.

Primary Physician Name

First Name

Last Name

Physician's Office Phone Number

(###)

###

####

Hospital Preference

Name of local preferred hospital

Emergency Authorization

In an emergency situation, The Learning Tree staff will provide transportation to an appropriate medical resource if required. All other children in the facility will be supervised by a responsible adult. The Learning Tree staff will not administer any drug or any medication without specific instructions from the physician or the child's parent, guardian, or full-time custodian. I, as the parent/guardian, authorize the center to obtain medical attention for my child in an emergency.

Today's Date

YYYY

The Learning Tree Enrollment Application

School Hours

Address

704-948-3561