Academic Year (YYYY / YYYY)

What would be your ideal start date?

Child's Name

Date of Birth

Place of Birth

Family Mail Address

City

Zip Code

Guardian 1

Mother

Father

First and Last Name

Cell Number

Email Address

Employer

Business Number

Home Phone Number

Guardian 2

Mother

Father

First and Last Name

Cell Number

Email Address

Employer

Business Number

Home Phone Number

Does Your Child Speak French?

Yes

Do Parents Speak French?

Yes, One parent

Yes, Both parents

None

What is the first language spoken at home?

What is the second language spoken at home, if any?

In case of an emergency, who can we call if we are unable to reach you

Name

Telephone

Family Mail Address

City

Zip Code

Emergency Doctor's Name

Emergency Doctor's Phone

PLEASE CHOOSE BELOW A SCHEDULE AND TIME FOR THE ACADEMIC YEAR, SEPTEMBER - JUNE

5 Days a Week: Monday - Friday
3 Days a Week: Monday, Wednesday, Friday
2 Days a Week: Tuesday, Thursday

Full Day: 8:00 am - 3:00 pm
Full Day + Enrichment: 8:00 am - 6:00 pm
Enrichment only: 3:00 pm - 6:00 pm

Medical Statements and Consent

Petits Poussins Dumbo is not permitted to administer any medication, if needed, please do so at home or after school.

I (we) authorize staff and Director of Petits Poussins Dumbo to obtain all necessary Emergency Medical treatment, in case of an emergency.

Do you authorize staff and director of Petits Poussins Dumbo to administer all necessary first aid care for your child, if necessary?

Yes No

Parent Initials

List any allergies your child has, or medical conditions, seizures, asthma, handicap, he/she has

Note: All allergies/medical conditions must be stated on the child's medical form. Additionally, a "Standing Order" from the Pediatrician will be required in order to administer an Epi-Pen, Benadryl, or any Asthma medication. Your child will not be admitted without it.

Does your child have any disability?

Yes No

If yes, Please Specify

Does your child have speech delay?

Yes No

If yes, Please Specify

New York department of health requires that all children are vaccinated for school entrance.

Do you vaccinate your child?

Yes No

I, hereby, authorize Petits Poussins Dumbo to provide care for my child.

I declare to the best of my knowledge that all statements made in this application are true.

First and Last Name (Guardian 1)

First and Last Name (Guardian 2)

Date

Amount

Payment For

Have a Coupon or Voucher Code?

By submitting this form, I have read and accepted the Privacy Policy.

Card Number

Name on Card

Expiry Date

Security Code

Total: