Application Form Please fill in application completely and legibly

Preschool Application Form Page 1

FOR OFFICE USE ONLY Start Date_____________

Date of Termination Status ______________________

__

Application Form

Please fill in application completely and legibly

STUDENT’S INFORMATION

_____________________________________________________________________________________

First Middle Last

Date of Birth: ______/______/_____ Age____________ Gender: Male Female Day Month Year

Child’s Home Address:

Address District_________________________

P.O. Box__________________________ Grand Cayman KY1-__________________ Cayman Islands _________________________________ _______________________________________

Place of Birth Nationality

SCHEDULE___________________________________________________________

Please tick which program you require:

Full Time (Mon- Friday) Part Time (4/5 half days or 3 full days per week)

One day per week

Estimated drop off time: __________________ Estimated pick-up time: ________________

Circle days to attend: AM Mon Tues Wed Thurs Fri PM Mon Tues Wed Thurs Fri

Meals you desire your child to eat: Breakfast Lunch

Student lives with: ___ Mother ___ Father ___ Stepmother ___ Stepfather ___ Grandparent ___ Guardian

Person responsible for paying child’s school fee: _______________________________________________

Photo Id

Preschool Application Form Page 2

PARENT OR GUARDIAN INFORMATION

1. Last Name:__________________________________ First Name:____________________________

Relationship to Child___________________________________________________________________

Address District_________________________

P.O. Box____________________ Grand Cayman KY1-______________ Cayman Islands

Home #:___________________ Cell #: _______________ Email Address: ________________________

Employer: ________________________________ work #:_______________ Extension #: ___________

2. Last Name:________________________________ First Name:______________________________

Relationship to Child___________________________________________________________________

Address District_________________________

P.O. Box____________________ Grand Cayman KY1-______________ Cayman Islands

Home #:_______________ Cell #: _______________ Email Address: ____________________________

Employer: ________________________________ work #:_______________ Extension #: ___________

Parents Marital Status: Married Separated Single Divorce

The child will also be released only to the persons on this application:

Name__________________________________Relationship_________________Phone_____________

Name__________________________________Relationship_________________Phone_____________

Name__________________________________Relationship_________________Phone_____________

Name__________________________________Relationship_________________Phone_____________

Enrolling Parent Signature ____________________________ Date _____________________

Preschool Application Form Page 3

Emergency Contact Information

List any person/s to be contacted in the event of an emergency in case the parents cannot be reached.

Last Name ____________________ First Name __________________Phone #_________

Last Name ____________________ First Name __________________Phone #_________

Physician______________________________________ Address: ________________________

Phone #:_______________________

TUITION AND FEES- All fees are effective as of 2

September

R EGISTRATION FEE: $50.00 – NON REFUNDABLE & MUST ACCOMPANY THIS APPLICATION- ALL FEES ARE PAYABLE IN ADVANCE BOTH FOR RETURNING AND NEW STUDENTS

Full time monthly- $475.00 for school fees plus $25.00 for breakfast and lunch. Total monthly fees -$500.00

Full time weekly: $135.00- all students Daily rate: $35.00- all students Part time: $350.00- all students Half Day: $25.00

Precious Gems opens from 7:00 AM to 5:30 PM (please tick box)

I agree that I am enrolling for _________________days per week at a cost of ________.

I agree to pay a registration fee at the time of enrollment. This fee is non- refundable.

I agree to pay in advance each month’s tuition.

I am aware that I will be charged a fee of $25.00 for late pick-ups.

There will be a charge of $40.00 for checks that are returned for non-payment.

NB: When the application form is signed, an agreement is made with the school to reserve a

space for your child. The school therefore keeps that space for your child each month. (Like

your rent to your landlord, who does not make deductions for your absence during the month),

we cannot make deductions for days or weeks when your child is absent due to illness or

vacation. Full payment must be made for the entire week or month.

Preschool Application Form Page 4

CHILD’S PREADMISSISON HEALTH HISTORY PARENTS REPORT

Child’s Name ^sex Birth Date

Father’s Name Does father live in home with child?

Mother’s Name Does mother live in home with child?

Has child been under regular supervision of physician? Date of Last Examination

OTHER SERIOUS OR SEVERE ILLNESS OR ACCIDENTS

DAILY ROUTINES Not applicable to school-age children.

What time does child get up? What time does child go to bed? Does child sleep well?

Does child sleep during the day? When? How long?

Diet Pattern Breakfast What are usual eating hours?

Noon Meal

Evening Meal

Any food dislikes? Any eating problems?

Are bowel movements regular? Yes No Words used for: Bowel Movement / Urination

What is usual time?

PAST ILLNESS – Check those child has had and approximate dates

Chicken Pox Asthma

Rheumatic Fever Hay Fever

Dates

Diabetes Epilepsy

Whooping cough Mumps

Dates

Poliomyelitis

Ten Day Measles (Rubeola)

Three Day Measles (Rebella)

Dates

Does child have frequent colds?

How many in the last year? List any allergies staff should be aware of.

Preschool Application Form Page 5

I HAVE PROVIDED COPIES OF THE FOLLOWING DOCUMENTS Birth Certificate

Immunization Form

Medical Consent

I/We _________________________________ (Parent/Guardian) give permission to Precious Gems Pre School Staff for my child/children to be transported from the school to a medical facility in case of an emergency and in the event that I/We are unable to be reached. I will be responsible for the cost of the ambulance service.

Signed ___________________________ Date: __________________

Does your child have any allergies or medical condition? Please describe:

Other physical health conditions or special requirement/s? _____________________________________________

______________________________________________________________________________________________

EMOTIONAL DEVELOPMENT_________________________________________________________________

How would you rate your child’s relationship with other children?

Excellent Good Fair Poor Unsure

What other group experience has your child had?

None Preschool Sabbath/Sunday School Other

Does the child have any special problems – fears? (Explain)

Parent or Guardian Signature Date

Preschool Application Form Page 6

DRESS CODE

School Uniforms and PE Uniforms are sold at the school.

School Uniforms are worn Mondays, Tuesdays & Wednesdays On Thursdays, PE uniform is worn

On Fridays, students are allowed to wear their own clothing that is appropriate for school.

School Uniform

Girls: Purple & White check dress & bloomers

Boys: Purple & white check shirt and short khaki pants Cost of school uniform: $25.00

PE Uniform Colours are Based on Houses

Purple – Tulip House Red – Hibiscus House Yellow – Sunflower House Cost for PE uniform is $18.00

For OFFICE USE ONLY

Date Fee Paid: ________________________________ Date Birth Certificate Received______________________

Date Immunization Record Received______________ Confirmed Start Date_______________________________