online enrollment application

Please schedule a tour before submitting application

I wish to enroll my child in
PrimaryElementary

Start Date*

Child's Full Name*

Preferred Name

Pronoun (ie she, he, they)*

Birthdate*

Address*

Phone

Email

Parent / Guardian Information

Marital Status
MarriedSingleSeparatedDivorcedWidowed

Who has legal custody?*

Legal Guardian (if other than the parents)

Parent / Guardian #1

Full Name*

Relationship to child*

Home Address*

Place of Employment

Cell Phone*

Work Phone

Home Phone

Parent / Guardian #2

Name*

Relationship to child*

Home Address*

Place of Employment

Cell Phone*

Work Phone

Home Phone

Health Information

Medical Provider*

Phone*

Insurance Information [if applicable]

Please list any specific allergies or intolerance to food, medication, etc, and action to take in an emergency

Chronic physical problems and pertinent developmental information

Emergency Contacts

Contact #1 Name*

Address*

Phone*

Contact #2 Name*

Address*

Phone*

Are these persons authorized to act on your behalf in a medical emergency involving your child?

YesNo

Person(s) authorized to pick up child [if different from above contacts]

Child's Personal History

Sibling(s) [names, ages]

Other household member(s)

Has the child attended another school or program? If yes, please give the name of school/program

Agreements

I agree to the following terms:

1. The parent/guardian gives authorization for the child to participate in walking field trips.
2. Puddletown School agrees to notify the parent/guardian whenever the child becomes ill and the
   parent/guardian will arrange to have the child picked up as soon as possible.
3. The parent/guardian authorizes Puddletown School to obtain immediate medical care if any emergency
   occurs when he/she cannot be located immediately.
4. The parent/guardian authorizes the use of child's photograph for Puddletown School.

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Puddletown School accepts any child whose family is interested in early education. We attempt to achieve a balance of age, gender and experience in the classroom. Generally, we are not equipped or licensed to care for children with special needs; therefore, any such care is conditional upon the consent of the head teacher and administrative coordinator. In all cases, applicants will be “interviewed” by the head teacher and another school representative (board member or administrative head) to get a sense of how the child will function in the classroom. Each child must be able to participate and substantially benefit from our program without risk to him/herself or other children. Puddletown School reserves the right to deny entrance into the program based on the interview process,or to ask that child be removed from the program after a trial period if the program does not appear to be a good fit for the student and other children. Puddletown School does not discriminate on the basis of race, color, national or ethnic origin in hiring, promoting, or training of employees, nor in the admissions, rights, privileges, programs, and activities of its students.