FBC FIRST STEPS PRESCHOOL AND MOTHER'S DAY OUT REGISTRATION

Child's Full Name *

Gender *

Male

Female

Child's Date of Birth * +

Child's Street Address (Street, City, State, Zip) *

I am registering my child for: (please select one) Summer Fun Days has closed, openings have been filled. *

Do you need Extended Preschool (12:00 p.m.- 2:30 p.m.) *

None

Tuesday only

Thursday only

Tuesday & Thursday

Are you also registering for Summer Fun Days?

Yes (0 remaining)

No (0 remaining)

Summer Fun Days

Tuesday Only (0 remaining)

Thursday Only (0 remaining)

Both Days (0 remaining)

Mother's Name *

Mother's Cell Number *

Mother's Street Address if Different (Street, City, State, Zip)

Father's Name

Father's Cell Number

Father's Street Address if Different (Street, City, State, Zip)

Email Address *

Please give the names of a person to call in case of emergency if parents can not be reached

Emergency Contact Name *

Emergency Contact Phone Number *

Emergency Contact Address (Street, City, State, Zip) *

Emergency Contact Relation to Child *

Are you currently a member of a church? If so, where?

MEDICAL INFORMATION

Name of licensed physician *

Phone Number *

Physician Address (Street, City, State, Zip) *

Hospital Preference (Street, City, State, Zip) *

List any special problems your child may have such as ALLERGIES, existing or previous illnesses, injuries or hospitalizations, or any medications prescribed for long-term continuous use and any other information which caregivers should be aware of. Please type NONE if not applicable. *

Does you child have a DIAGNOSED FOOD ALLERGY? *

Yes

If yes to DIAGNOSED FOOD ALLERGY, please explain briefly *

Does your child have a food intolerance? *

Yes

If yes to food intolerance, please explain briefly *

We understand parents may have specific food preferences. If there is something you would like us to know so we can be helpful, please explain briefly

IMMUNIZATION RECORDS *

I will attach a copy of my child's current immunization records.

I will mail/drop off a copy of my child's immunization records.

Attach Immunization Records Here

HEALTH CARE PROFESSION STATEMENT *

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 will submit it to the child-care operation. I will mail/drop off a copy of my child's immunization records.

Attached is a signed and dated copy of a health care professional’s statement.

Attach Health Care Professional Statement Here

MEDICAL EXCLUSION Medical diagnosis and treatment conflict with the tenets and practices of a recognized religious organization or of reason of conscience, which I adhere to or am a member of; I have attached a signed and dated affidavit stating this. Please answer NO if this does not apply. *

YES

Attach signed and dated medical exclusion affidavit here.

Varicella (chickenpox) vaccine is not required if your child has had chickenpox disease. Has your child had the chickenpox? *

YES

My child had varicella disease (chickenpox) on or about the following date: * +

AUTHORIZATION FOR MEDICAL ATTENTION

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 either the licensed physician or hospital listed above. I give my consent for the physician or facility to secure any and all necessary emergency medical care for my child.

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ACTIVITIES PERMISSION FORM

FIELD TRIPS/TRANSPORTATION: First Steps will provide van transportation for field trips. However, you may arrange to drive your child to the field trip. First Steps may take short walking field trips that are a regular part of the program.

I understand that:

I will be notified in writing before a field trip takes place informing me of the destination and time of the trip.

If I do not wish for my child to participate in a particular field trip, I should keep

him/her home on that day as there will not be adequate supervision for him/her in the classroom.

I understand I must install my child’s car safety seat in the field trip van due to a mandate by the State of Texas to provide transportation.

My child may participate in school sponsored field trips *

YES

PHOTOS: Your child/family may be photographed and/or videoed in his or her classroom or at class parties. We may use these photos for educational and program promotional material. Additionally, we may post these photos to our church’s website: www.firstamarillo.org.

I give permission for my child/family photos and videos to be used in educational and promotional literature and also on FBC Amarillo’s website. *

YES

WATER FUN: Occasionally, we may have water activities here on campus such as sprinkler play,
splashing/wading pools, slip n slide, inflatables, and water table play. In the event of this you will be notified in writing before the event takes place.

I give permission for my child to participate in water activities. *

YES

DIRECTORY: Occasionally, our teachers may decide to put together a Class Directory with your child’s name, address, and phone number listed. This directory is used only for classroom needs such as invitations to birthday parties, thank you cards, etc.

I give permission for my child’s information to be listed in the class directory. *

YES

LUNCH AND SNACKS

I do understand that if my child stays for Extended Preschool, I am responsible for providing my child a lunch *

YES

I do understand that I am responsible for providing my child a daily snack. *

YES

By signing below, I agree to all the above selections for the entire school year, unless I notify the program in writing. *

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SECURITY INFORMATION

We are committed to keeping each child safe. We have security protocols in place to ensure this happens. One is the use of security codes. If you or anyone listed in your child’s file cannot pick up your child, please call us and tell us who will be coming and then you will need to give that person your security code. Once we verify their I.D. and hear them say the security code, we will release your child to the approved person. Security codes can be sibling’s names or pet’s names, nicknames, favorite sports team, simply anything you can remember in case of an emergency.

Child's Name *

Security Code *

I authorize First Steps to release my child to the following individuals (other than parents):

Name

Phone Number

Name

Phone Number

Do NOT release child to the following person(s):

Name(s)

RECEIPT OF HANDBOOK

The 2023-2024 Operational Policies & Parent Handbook is available on the internet at:
https://www.firstamarillo.org/first-steps We are asking that you consider using the internet to access and review the 2023-2024 Handbook. Using the internet to access the handbook will limit the amount of printed paper at the time of registration. If any changes occur in the handbook, a note will be sent home with your child explaining the changes and a sheet for parents to sign.

Please check one box and sign below: *

I will review the 2023-2024 Operational Policies & Parent Handbook on the internet. My signature below acknowledges receipt of the Operational Policies & Parent Handbook.

I prefer a paper copy of the Operational Policies & Parent Handbook.

I acknowledge receipt of the Operation Policies & Parent Handbook. *

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RECEIPT OF EPIDEMIC/PANDEMIC POLICY BOOK

Please check one box and sign below: *

I will review the 2023-2024 Epidemic/Pandemic Policy Handbook on the internet. My signature below acknowledges receipt of the Operational Policies & Parent Handbook.

I prefer a paper copy of the Epidemic/Pandemic Policy Handbook.

I acknowledge receipt of the Epidemic/Pandemic Policy Handbook. *

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