Child's Name *

First Name

Last Name

Bloom Start Date *

MM

DD

YYYY

Desired Schedule *

M,W,F

T,TH

Other

Birth Date

MM

DD

YYYY

Gender *

Female

Male

Child's Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

First Parent/Guardian Name *

First Name

Last Name

Phone number where you can be reached when child is in school

(###)

###

####

Alternate Phone

(###)

###

####

2nd Parent/Guardian Name

First Name

Last Name

Phone number where you can be reached when child is in school.

(###)

###

####

Alternate Phone

(###)

###

####

Contact #1 *

First Name

Last Name

Cell phone *

(###)

###

####

Is this person authorized to pick your child up from school? *

Yes

No

Contact #2

First Name

Last Name

Cell phone *

(###)

###

####

Is this person authorized to pick your child up from school? *

Yes

No

Contact #3 *

First Name

Last Name

Cell phone *

(###)

###

####

Is this person authorized to pick your child up from school?

Yes

No

AUTHORIZED RELEASE: I hereby authorize the school to allow my child to leave the premises ONLY with those designated on my emergency contact list. Children will only be released to a parent/guardian or person designated by the parent/guardian with 1) prior notice that there will be a diversion from the typical pick up person and 2) after verification of a photo ID. *

Yes

I understand that all tuition and fees are non-refundable and based on equal monthly payments. *

Yes

I hereby acknowledge I have received a Parent Handbook. I have read and agree to all of Bloom Preschool's policies. I have received and read a copy of Bloom Preschool's Conflict Resolution Policy *

Yes

I hereby acknowledge the receipt of Bloom’s Illness Policy. I have read the policy and will not request the Bloom staff to make exceptions regarding the policy. I agree that my family will cooperate with Bloom staff regarding my child being excluded from attendance due to illness. I agree to keep my child from attending per request of the Bloom staff and in accordance to the Bloom Illness Policy. I agree that if I am called to pick my child up from Bloom due to illness, I will do so within 30 minutes from the time that I am contacted by Bloom staff. *

Yes

I hereby consent for my child to be transported and supervised by the Bloom’s employees: for emergency care & on field trips *

Yes

I hereby give my consent for my child to participate in water activities: sprinkler play, splashing/wading pools, water table play *

Yes

I hereby give my consent for Bloom's employees to provide emergency care *

Yes

I understand I can find a copy of Child Care Licensing Minimum Standards to review onsite at Bloom *

Yes

I understand that I can contact our local child care licensing office at (512) 834-3426, the DFPS child abuse hotline at (800) 252-5400 and find the DFPS website at http://www.dfps.state.tx.us *

Yes