Register to Enroll for 2024-2025 School Year Let’s get your PreK or Transitional K5 student enrolled at CLC!Please fill out all enrollment info below OR download and fill out form and mail or bring into the office, and we will be in touch shortly! DOWNLOAD ENROLLMENT FORM Student's Name * First Name Last Name Student's Birthdate * MM DD YYYY Students Age * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Parent Contact #1 * First Name Last Name Relationship to student * Primary Contact Number * (###) ### #### Secondary Contact Numer * (###) ### #### Parent Contact #2 * First Name Last Name Relationship to student * Primary Contact Number * (###) ### #### Secondary Contact Number * (###) ### #### Emergency Contact #1 * First Name Last Name Relationship to student * Primary Contact Number * (###) ### #### Secondary Contact Number (###) ### #### Emergency Contact #2 * First Name Last Name Relationship to student * Primary Contact Number * (###) ### #### Secondary Contact Number (###) ### #### Please list any allergies and/or medial issues we should know about About My Child * Please list three strengths Three Areas To Work On * What are three goals you would like to see your child achieve this year? * Child's Favorite Color * Favorite TV Show * Favorite Book * Favorite Food * What else would you like us to know about your child? My Child Responds Well To My Child Doesn't Not Respond Well To You DO have my permission to use photos and videos of my child on the CLC media sites * YES NO Email Address #1 * Email Address #2 Do you use Facebook? * Yes No If so, would you like to be added to our private parent group? Yes No Please list all siblings and ages * People who are able to pick up my child: * *We will check for ID prior to child being dismissed to the person picking them up Explain what you want your child to gain by coming to our program * Does your child speak fluent English? Yes No If not, what language does your child speak? Has your child participated in a weekly preschool education program or daycare program in the past? * Yes No If YES, was this a positive or negative experience for your child? * Yes No If no, please explain Is your child potty trained? * Definition: Child is able to go tot he potty on his/her own without being prompted and is not in a pull-up or diaper. Students MUST be potty trained before starting our program unless are medical issues. Yes No Are you aware of any emotional or behavioral concerns or diagnosis withy your child? * No Yes If yes, please explain Has your child been referred for testing or tested for any special needs; including but not limited to emotional, behavioral, speech, or developmental delays? * Yes No If YES, please provide a brief explanation of the needs to be maintained by the school on a confidential basis. *Coastal Learning Center will require a copy of any assessments in order to plan for your child (and will use such on a confidential basis with your child's teachers to plan for his/her class). In the case of an accident or serious illness, I request Costal Learning Center LLC Administration &/or Staff to contact me or my emergency contacts. If Coastal Learning Center Administration &/or Staff is unable to reach me or my emergency contacts, i hereby authorize Coastal Learning Center LLC Administration &/or Staff to all the physician listed below and to follow his or her instructions. If it impossible to contact the physician, Coastal Learning Center LLC Administrations &/or Staff may make whatever arrangements necessary. * I consent I do not consent Insurance Carrier * Policy Number Child's Primary Physician * Physician Office Phone * (###) ### #### Hospital Preference * Parent Name * First Name Last Name Today's Date * MM DD YYYY Thank you for enrolling your student! Lisa Bullard from our office will be reaching out very shortly.
