Home Phone Applying For Subsidy Email Address Applying For Subsidy Applying For Subsidy M / W / F: 8:30 – 11:00 am M / W / F: 11:30 - 2:00 pm T / TH: 8:30 – 11:00 am T / TH: 11:30 - 2:00 pm Child's Name Birthdate Address City Postal Code Home Phone Parent(s) / Guardian’s Information: For tax purposes, please check box for which parent is to receive tax receipt Parent /Guardian’s Name: Home Phone Cell Phone Email Address: (If different from above) City: Postal Code Occupation Postal Code Work Phone Work Address Parent(s) / Guardian’s Information: For tax purposes, please check box for which parent is to receive tax receipt Home Phone Cell Phone Email Address Address: (If different from above) City Postal Code Occupation Work Phone Work Address Will your child be at least three (3) years of age as of September 9th, 2024? Will your child be at least three (3) years of age as of September 9th, 2024? yes no Are_there_any_custody/visitation_arrangements? Are_there_any_custody/visitation_arrangements? yes no If You Answered Yes Please Provide Details Siblings: Please list all siblings and their ages: Family Physician: Phone Number: *Address: Health Care # (optional) Are immunizations up to date? Are immunizations up to date? yes no *Does your child have Allergies? *Does your child have Allergies? yes no Please list all allergies: Severe Allergies: Severe Allergies: yes no If YES, does your child require an Epipen/medication? If YES, does your child require an Epipen/medication? yes no Policy requires a signed Medication Release Form and an Epipen to be kept at school at all times. Please list any foods your child is not allowed to have due to a special diet for health or religious reasons: Has your child had any medical or emotional conditions requiring or receiving treatment or supervision? Has your child had any medical or emotional conditions requiring or receiving treatment or supervision? yes no If YES, please describe: Does your child have any ongoing medications being taken at home? Does your child have any ongoing medications being taken at home? yes no Has your child ever been hospitalized? Has your child ever been hospitalized? yes no If YES, please describe: Does your child have any ongoing medications being taken at home? Does your child have any ongoing medications being taken at home? yes no Has your child ever been hospitalized? Has your child ever been hospitalized? yes no For what reason? *Parent’s/Guardian’s Signature: Date: *Parent’s/Guardian’s Signature: Date: *Name: *Phone #’s: *Address: Relationship to child: Relationship to child: *Name: *Phone #’s: *Address: Relationship to child: *Name: *Phone #’s: *Address: Relationship to child: *Name: *Phone #’s: *Address: Relationship to child: *Name: *Phone #’s: *Address: Relationship to child: I am the parent/guardian of Signature Date I parent guardian child's name *Parent’s/Guardian’s Signature: Date: A I herby give my consent *Parent’s/Guardian’s Signature: Date B I hereby give my consent date childs name *Parent’s/Guardian’s Signature: Date How did you hear about Fuzzy Pickles Preschool? How did you hear about Fuzzy Pickles Preschool? Friend Referral: Advertising: Billboard Social Media Drive by School Our Website 10 + 14 = Submit
