Please write
the school
Pre-K Registration Form
year in the
box
School Year
PROVIDER LEGAL NAME: (This section to be completed by the provider)
SCHOOL/SITE NAME:
CHILD INFORMATION (Please print name exactly as it appears on the birth certificate.)
CHILD’S LAST NAME: | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
CHILD’S FIRST NAME: | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
CHILD’S MIDDLE NAME: | | | | | | | | | | | | | | | | | | NAME SUFFIX:| | | | (i.e. Jr, Sr, II,III)
CHILD’S SOCIAL SECURITY#: D.O.B. (MM/DD/BY): SEX: [ ]M [ ]F
HOME ADDRESS (Do not enter PO Box Info): COUNTY:
CITY: STATE: GA ZIP: HOME PHONE: ( )
If the Student is transferring from another Pre-K, please provide the following:
Previous School Name: __________________________________ Last Date in Attendance: ____________
PARENT/GUARDIAN INFORMATION
Parent/Guardian #1 - LAST NAME: FIRST: MIDDLE INITIAL:
Home Address (If different from child):
City: State: Zip:
Home Phone: ( ) Cell Phone: ( )
Email Address:
Place of Employment: Work Phone: ( )
Address:
City: State: Zip:
Parent/Guardian #2 - LAST NAME: FIRST: MIDDLE INITIAL:
Home Address (If different from child):
City: State: Zip:
Home Phone: ( ) Cell Phone: ( )
Email Address:
Place of Employment: Work Phone: ( )
Address:
City: State: Zip:
EMERGENCY CONTACT INFORMATION (Persons to contact in the event that either parent/guardian cannot be contacted)
NAME RELATIONSHIP CELL PHONE ALTERNATE PHONE EMAIL
1.
2.
I verify the above information to be correct, and I understand that completion of this form does not guarantee placement in a Pre-K class. If
my child is placed in Georgia's Pre-K Program, I agree that my child will attend the program for the required number of hours and days as
prescribed by the Georgia Department of Early Care and Learning and outlined by the center where my child is enrolled. I understand that
failure to comply with these attendance requirements could result in disenrollment. I understand that I cannot register my child without
appropriate age documentation. I have attached a copy of appropriate age documentation to this registration form.
Signature Parent/Guardian: DATE: ________________
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CHILD MAINTENANCE
CHILD’S LIVING ARRANGEMENTS: [ ]BOTH PARENTS [ ]MOTHER [ ]FATHER [ ]OTHER
CHILD’S LEGAL GUARDIAN: [ ]BOTH PARENTS [ ]MOTHER [ ]FATHER [ ]OTHER
THE CHILD MAY BE RELEASED TO THE PERSON(S) SIGNING THIS AGREEMENT OR TO THE FOLLOWING:
NAME ADDRESS RELATIONSHIP CELL PHONE
1.
2.
3.
4.
CHILD’S PHYSICIAN OR CLINIC’S NAME (CHILD’S PRIMARY HEALTH SOURCE): .
DATE OF LAST FULL HEALTH SCREENING:______________________ PHONE: ( )
MY CHILD HAS THE FOLLOWING SPECIAL NEED(S):
THE FOLLOWING SPECIAL ACCOMMODATION(S) MAY BE REQUIRED TO MOST EFFECTIVELY MEET MY CHILD’S
NEEDS WHILE AT THIS CENTER:
MY CHILD IS CURRENTLY ON MEDICATION(S) PRESCRIBED FOR LONG-TERM CONTINUOUS USE AND/OR HAS
THE FOLLOWING PRE-EXISTING ALLERGIES, ILLNESS, OR HEALTH CONCERNS:
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GENERAL RELEASE
I verify the above information to be correct and true. I hereby grant permission for the information
provided in the preceding Registration Form to be distributed to Pre-K providers, the Department of Early
Care and Learning (DECAL), and certain agencies or those entities contracted by Pre-K providers or DECAL
which shall include, but not be limited to, the Georgia Department of Education, and colleges/universities.
SIGNATURE (Parent/Guardian): ____________________________________________
DATE: __________________________________________
PHOTOGRAPH/VIDEOTAPE RELEASE
I hereby grant permission for the Pre-K provider specified below, the Georgia Department of Early
Care and Learning (DECAL) and certain agencies or entities contracted by the Pre-K provider or
DECAL which shall include, but not be limited to, the Georgia Department of Education, and
colleges/universities, to record the participation and appearance of my child,
_____________________________, by photograph and/or videotape in connection with daily Pre-K
activities for the purposes of news releases, reporting, and assessing the progress of children and
the program. DECAL and its contractors are authorized to exhibit or distribute such photograph(s)
and/or videotape in whole or in part without restrictions or limitations for any educational or
promotional purpose that DECAL deems appropriate. Such photograph(s) and/or videotape may, for
example, appear in printed or visual materials for DECAL and/or on DECAL’s web site.
The undersigned hereby jointly and severally releases, acquits, forgives, and discharges the Pre-K
provider, DECAL, and other entities contracted by the Pre-K provider or DECAL, from any actions,
agreements, claims, controversies, demands, judgments, liabilities, proceedings, and suits, whether
arising in equity or in law regarding such participation and appearance by said child.
This release shall remain binding upon all successors in interest and personal representatives of the
parties, to the extent permitted by law.
PRE-K PROVIDER NAME/ADDRESS: ______________________________________________
SIGNATURE (Parent/Guardian): _________________________________________
DATE:
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