Enrollment · Creative Hands & Brilliant Minds

Child information

First name* Last name* Middle name Preferred name / nickname Date of birth* Gender Home language* Other language Lives with Child's address is the same as Parent 1 Street address City State ZIP code

Parent / Guardian 1

First name* Last name* Relationship* Mobile phone* Work phone Email* Street address* City* State* ZIP code* Employer Employer phone Custodial status Custody / court order notes

Parent / Guardian 2 (optional)

Add a second parent / guardian

First name Last name Relationship Mobile phone Email Street address City State ZIP code Employer

Emergency contacts (at least 2)*

Indiana requires at least two emergency contacts. You can add up to five.

#1 First name* Last name* Relationship* Primary phone* Secondary phone

#2 First name* Last name* Relationship* Primary phone* Secondary phone

#3 First name Last name Relationship Primary phone Secondary phone

#4 First name Last name Relationship Primary phone Secondary phone

#5 First name Last name Relationship Primary phone Secondary phone

Authorized pickup persons

People (besides parents) allowed to pick up the child. Up to ten.

#1 First name Last name Relationship Primary phone ID they will show

#2 First name Last name Relationship Primary phone ID they will show

#3 First name Last name Relationship Primary phone ID they will show

#4 First name Last name Relationship Primary phone ID they will show

Health & medical

Does the child have allergies?

Allergen Severity Additional notes

Does the child take medications?

Medication Dosage Frequency

Any medical conditions? Medical conditions

Has an IEP or 504 plan? IEP / special needs notes Physician name* Physician phone* Clinic / practice Insurance carrier Policy number Dietary restrictions

Immunizations are up to date Immunization record (PDF, JPG or PNG, max 5 MB)*

Requested program & schedule

Program requested* Schedule type*

Days requested*

Preferred start time Preferred end time Desired start date* How did you hear about us? Who referred you? Additional notes

Consents

I authorize emergency medical treatment if needed.* I understand the child is released only to authorized persons.* I give permission for field trips.* I authorize applying sunscreen.* I acknowledge receiving the parent handbook.* I acknowledge the payment and late-fee policy.*

I allow photos/video of my child for internal use (the child's portfolio). I allow photos/video of my child for marketing (website, social media).