CHILD ENROLLMENT FORM

Child's Full Name(Required)

First Last

Child's Birthdate(Required)

Gender At Birth(Required)

Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent/Guardian #1's Name(Required)

First Last

Cell Phone(Required)

Email(Required)

Employer & Position at Work(Required)

Work Phone #(Required)

Parent/Guardian #2's Name(Required)

First Last

Cell Phone #(Required)

Email(Required)

Employer & Position at Work(Required)

Work Phone #(Required)

Parents' Marital Status(Required)

Single

Married

Seperated

Divorce

Parents' Info(Required)

If you chose any of the first three options, please give the details on the situation.

Name of Emergency Contact #1 (Must live within a 45 Mile Radius of Sioux Falls):

First Last

Relationship to Emergency Contact #1

Phone # of Emergency Contact #1

Name

First Last

Name of Emergency Contact #2 (Must live within 45 mile radius of Sioux Falls)(Required)

First Last

Relationship to Emergency Contact #2(Required)

Phone # of Emergency Contact #2(Required)

Hospital Preference(Required)

Child's Physician(Required)

First Last

Phone # of Child's Physician(Required)

Child's Dentist(Required)

First Last

Phone # of Child's Dentist(Required)

Untitled

What type of message do you want to send?

General Contact

Prayer Request

Praise Report

All allergies (Doctor's note must be provided email to [email protected] or upload below)(Required)

Doctor's Note of Allergies

Max. file size: 10 MB.

Medical Conditions / Diseases / Chronic Illnesses

Prescribe Medications

Has your child ever been hospitalized? (Explain)

Has your child ever had trouble with his/her hearing or vision? (Explain)

Has your child ever had any serious accidents or poisoning? (Explain)

Does your child require any special accommodations? (Explain)

List Student's *Last* Name for the SDIS Record

To ensure the South Dakota Department of Health is aligning with the Health Insurance Portability and Accountability Act (HIPAA) Omnibus Rule, a School Official must obtain parent, guardian or legal representative agreement before accessing a student's immunization record in the South Dakota Immunization Information System (SDIS). No student record shall be accessed by a School Representative in the SDIS without parent, guardian or legal representative agreement.

Parent / Guardian signature to give permission of the below:(Required)

I give permission to Sioux Falls First Learning Center Center at 6300 W 41st Street, Sioux Falls, SD 57106, access to the above child's immunization record in the South Dakota Immunization Information System.

Today's Date(Required)

In lieu of written consent, verbal consent was obtained from:

First Last

Signature

Date

Infant Program (4 Weeks - 12 Months)

Please mark the desired classroom placement for your child below. Official classroom placements are made according to availability and are not always guaranteed. Half Day Class Times AM: 8:30-11:14 PM: 12:30-3:15

Toddler Program (12 Months - 3 Years)

Preschool Program (3 Years - 5 Years)

*All children must be completely potty trained to attend preschool class offerings* Half Day Class Times AM: 8:30-11:14 PM: 12:30-3:15

Pre-K

Kinder Ready

School Age Program (5 Years - 12 Years)

*A registration form for Summer Blast and each new School Year must be completed when registration opens in order to reserve a spot. We do not automatically enroll students in these programs from year-to-year*

Please indicate which school your child attends

Parent #1's Signature of Agreement(Required)

Parent #2's Signature of Agreement(Required)