Preschool Application Form Kidz Lane Incorporated2925 N Olney Street Indianapolis, IN 46218 Name * First Name Last Name Date of Birth * MM DD YYYY Age 6 Weeks -11 Months 1 2 3 4 5 6 7 8 9 10 11 12 Home Phone (###) ### #### Guardian Cell Phone 1 (###) ### #### Guardian Cell Phone 2 (###) ### #### Email * Guardian's Information Guardian's Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Employer Monthly Salary Guardian's Name First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Employer Monthly Salary List other family members attending Kidz Lane Inc. Medical Consent in Case of Emergency: In the event of a medical emergency, I would like Kidz Lane Inc. to contact Doctor's Name Phone (###) ### #### * If the above doctor is not available, I authorize my child to be taken to the nearest hospital. I give permission for said hospital and/or doctor to treat my child. Yes * In the event of medical emergency when I cannot be reached, I hereby authorize the administration of any medical procedure deemed necessary by the doctor, or should doctor be unavailable, by any other physician or medical personnel. Yes *Parents will be responsible for all medical costs Medical Facts and History Communicable Diseases * Mumps Measles German Measles Chicken Pox Allergies * Please list any allergies or reactions to any food, animals, pediatric asthma etc. Its very important to mention nut allergies. If none, indicate "N/A". Medications * List any ongoing chronic medications that might impact the child's wellbeing while at the preschool. If none please indicate "N/A" Medical Conditions * Please list any existing medical conditions that may impact the child's health and wellbeing in the preschool. If none, please indicate "N/A" Limitations to Physical Activity * Please list any existing medical conditions that may restrict the child's physical activity in the preschool. If none, indicate "N/A". Special Equipment Please list any orthodontic devices/prosthesis, glasses, etc. Special Diets Any special diet/supplement that are medically prescribed should be included. Authorization & Release for Epipens and Inhalers Please check the applicable option Epipen (if your child may need an epipen administered during school hours) Child will be carrying Epipen on their person Inhaler (if your child may need an inhaler administered during school hours) Directions for use Please indicate dosage, frequency of use, etc. Consent to Administer I, the parent/legal guardian of the child listed above, request that the administration of the above noted medication be provided. I understand that the service will be provided by a person with no medical or nursing training. All training will be parent's responsibility. I agree to provide Kidz Lane Inc. with an updated medical statement if there is any change in the physician's instructions with respect to medication. I hereby release Kidz Lane Inc., its employees and contractors from all manner of actions, causes of actions, lawsuits, damage or injuries, however caused, arising out of the administration or failure to administer medication as provided herein. I agree Photo Consent * I hereby give my permission to the staff of Little Barn Academy to photograph my child. I understand that these photographs may be posted in the academy or on Little Barn Academy's website or social media where they may be viewed by individuals other than preschool participants. I acknowledge further that parents of other preschool learners might take pictures of their own children that might include my child. I agree As parent/legal guardian of the above applicant, I do hereby grant permission for my child to participate in all school activities, which form part of the daily routine. This includes permission to use all of the play equipment and participate in all of the activities of the school, and to leave the school premises under the supervision of a staff member for scheduled field trips. I agree Acknowledgement * Kidz Lane Inc. endeavors to adhere to the highest standard of care while looking after your child. However, The Kidz Lane Inc. cannot be held liable for any injury or loss of any nature suffered, which occurred due to events beyond its reasonable control. The Kidz Lane Inc. cannot be held liable for the actions of third parties not associated with Kidz Lane Inc. or natural disasters. This indemnity does not include the negligence of Kidz Lane Inc., its agents or employees. I agree Electronic Signature of Parent/Guardian * Thank you!
