ENROLLMENT APPLICATION AND AGREEMENT

1. Name of Child: ______________________________Date of Birth_________

2. Address: Street_________________________________________________

City _______________Zip__________Phone_________________

3. Email Address:__________________________________________________

4. Enrollment Date:________________

5. Mother/Guardian:_____________________ Cell Phone__________________

Employer:___________________________ Phone__________________

6. Father/Guardian:______________________Cell Phone__________________

Employer:___________________________Phone__________________

7. Persons to whom The Arbor is authorized to release the child (if other than above)

____________________________________Relationship_________________

____________________________________Relationship ________________

Under no circumstances will The Arbor release a child to anyone not identified
above or not otherwise known to staff without specific authorization from the
parent or guardian. The parent or guardian will be certain that staff is aware of
the child’s arrival or departure.

8. Persons whom you authorize The Arbor to contact in the event of a medical or
other emergency in which the child’s parents, guardian or (if applicable) physician are unavailable:

____________________________________Relationship________________

Telephone Numbers:_____________________________________________

____________________________________Relationship________________

Telephone Numbers:_____________________________________________

9. Child’s Physician:_________________________Phone________________

Address:_____________________________________________________

10.Diagnosis of Condition:_________________________________________

____________________________________________________________

____________________________________________________________

11. Pertinent social/family circumstances which might affect child’s daily functioning:

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

12. List any special problems or needs, including allergies, which would limit the child’s
diet and/or participation in The Arbor program:

Program Restrictions:_________________________________________________

__________________________________________________________________

Dietary Restrictions:__________________________________________________

__________________________________________________________________

13. Unusual events or circumstances occurring during program hours,including
discovery of serious communicable diseases, in children or staff, will be
brought to the attention of the parent or guardian.

14. Conferences with the parent or guardian concerning the child’s progress
will be scheduled quarterly, or at the express request of the parent or
guardian.

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General Authorization: We hereby grant to The Arbor School permission for the subject child to take part in all program activities and use all indoor and outdoor equipment, subject to restrictions listed in paragraph 12 above, or in the Physician’s Report.

Medical Authorization: We hereby grant to The Arbor School permission to take whatever action in its judgment may be necessary in supplying emergency medical services to the subject child. We understand that, consistent with the circumstances of the situation and available time, The Arbor will contact and follow the instructions of the child’s parent or guardian, physician or the person authorized by us to act in our behalf to be contacted in an emergency. In the event The Arbor is unable to contact the parent or guardian, physician, or other authorized person, then we hereby grant permission to The Arbor to contact and comply with the advice of an available physician, ambulance personnel, or emergency room personnel. We hereby agree that we will be solely responsible for and will promptly pay any expenses incurred by The Arbor in making emergency medical care available to the subject child.

Program Acknowledgment: We have received a copy of the daily activities and policies of The Arbor School and have had the opportunity to discuss them with The Arbor. We have reviewed each of the provisions of the Agreement, and hereby agree to comply with all provisions hereof.

Mother or Guardian________________________________Date___________

Father or Guardian________________________________Date___________

I have reviewed with the parent or guardian the daily activities and policies of The Arbor School, and agree to accept enrollment of subject child in accordance with stated policies.

Director_________________________________________Date___________