Margolin Hebrew Academy Leach Early Childhood Information Forms 2024-2025

Child/Family information

Child's name *

Birthdate * +

Age: years *

Which class will your child be enrolling in this school year? *

Address *

City *

State *

Zip code *

Mother's Phone Number *

Mother's Email *

Mother's Occupation: *

Mother's Approximate Work Hours: *

Father's Phone Number *

Father's Email *

Father's Occupation: *

Father's Approximate Work Hours: *

Emergency contacts

Emergency contact 1 name *

Emergency contact 1 phone number *

Relationship to child *

Parent

Neighbor

Friend

Family member (please indicate relationship) Family member (please indicate relationship)

Emergency contact 2 name *

Emergency contact 2 phone number *

Relationship to child *

Parent

Neighbor

Friend

Family member (please indicate relationship) Family member (please indicate relationship)

Services

Does your child require aftercare from 2:00-3:45/M-Th and 2:00-3:00/Fri? (This question pertains to Pre-K students only)

Yes

No

Medical Information

Name of child's pediatrician: *

Additional medical care providers:

Address of Pediatric Office: *

Phone number of Pediatric Office: *

Name of hospital to transport child to in the event of an emergency: *

TN Immunization records: Mandatory for students enrolling in Pre-K 3, Kindergarten, and all new students.

Does your child have any allergies? *

Yes

No

If you answered "yes" to the above question, please list and explain your child's allergies and the methods to treat an allergic reaction:

Does your child have asthma? *

Yes

No

If you answered "yes" to the above question, please explain your child's method of treatment and plan for an asthmatic episode :

Has your child ever received any intervention services? (i.e. speech therapy, early intervention, occupational therapy, physical therapy, behavioral therapy, play therapy, or academic supports) *

Yes

No

If you answered "yes" to the above question, please list and explain your child's intervention services:

I give my permission for MHA to contact my child's medical provider(s) in the event of an emergency: *

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Transportation Information

I give permission for the following people to pick my child after school:

+-

Additional Information

I acknowledge that I have received a copy of the Tennessee Department of Education Rules for Childcare and agree to accept and adhere to the policies and procedures. *

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I acknowledge that I have received and read the Parent Handbook from the Early Childhood Director and agree to accept and adhere to the policies and procedures. *

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The faculty/ staff assigned responsibility for the care and education of my child has permission to access my child’s health records. *

clear

I give permission for my child's photograph, digital or video recording, likeness, or artwork to be used in featured publications, web pages, or social media sites. Circulation of the materials could be worldwide and there will be no compensation to me or my child for the use. *

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I give consent for my child to participate in the Child Protection Unit led by the Early Childhood Staff I understand that this unit is a requirement made by the TN Department of Education and will focus on concepts such as personal safety, appropriate touching, and reporting a problem to a grown up. *

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Please provide any additional information you think we should know about your child: