HUSD Early Childhood Programs

HUSD Early Childhood Programs

OUR VISION

The Higley Unified School District prides itself on providing quality educational experiences. We feel that enriched early childhood environments not only provide extraordinary opportunities for young children, but also form the foundation for a successful educational career. We have designed our Brilliant Beginnings Program for three and four year olds and our Kindergarten Prep program for four and five year olds who will attend Kindergarten the following school year to provide a loving, safe, and nurturing child-centered educational experience. The goal of our Early Childhood Development Center programs is to bring teachers, parents and community together with a common vision to enhance the lives of children and their families.

Connect Engage Inspire

Master educators will guide your child in learning new skills, help your child develop a sense of belonging and foster a love of learning and celebration of life each and every day. The curriculum will provide a foundation for inquiry and will challenge each individual student. We are committed to providing meaningful and developmentally appropriate educational experiences for your child’s intellectual, social, emotional, creative and physical development. We limit our class sizes to maintain the Arizona student/teacher ratio. We feel that maintaining this ratio enables our early childhood certified teachers to provide students with more individualized and quality instruction on a daily basis.

STAFF QUALIFICATIONS

All Brilliant Beginnings and Kindergarten Prep teachers are highly qualified, early childhood certified teachers. Instructional aides are selected for their depth of educational training and the quality of prior experiences. Teachers and aides participate in continued formal training each year as well as ongoing professional development opportunities in the areas of classroom management, discipline and child psychology.

In addition to our regular Brilliant Beginnings and Kindergarten Prep programs we also offer these new preschool programs.

MANDARIN DUAL LANGUAGE PROGRAM

Our Mandarin Dual Language class is located at our Cooley Early Childhood Development Center. The class meets 5 days a week from 7:45 to 2:45 and is for four to five-year-olds who will be going to kindergarten the next school year. Students in the Mandarin Dual Language program will receive instruction in both Mandarin and English during their school day. Foundational Mandarin language experience along with our Kindergarten Prep curriculum will provide meaningful, developmentally appropriate learning experiences for your child’s social, emotional, intellectual, creative and physical development to prepare them for the rigors of kindergarten and will feed into the Mandarin Immersion Program at Coronado Elementary where students will build upon this foundation. Before and after care is available through Kids Club.

SPANISH DUAL LANGUAGE PROGRAM

Our Spanish Dual Language class is located at our Sossaman Early Childhood Development Center.The class meets 5 days a week from 7:45 to 2:45 and is for four to five-year-olds who will be going to kindergarten the following school year. Students in the Spanish Dual Language program will receive instruction in both Spanish and English during their school day. Foundational Spanish language experience along with our Kindergarten Prep curriculum will provide meaningful, developmentally appropriate learning experiences for your child’s social, emotional, intellectual, creative and physical development to prepare them for the rigors of kindergarten and will feed into the Spanish Immersion Program at San Tan Elementary where students will build upon this foundation. Before and after care is available through Kids Club.

HIGHLY GIFTED PRESCHOOL PROGRAM

For four-year-olds with IQ’s in the 99th percentile, our Highly Gifted Preschool class is located at our Sossaman Early Childhood Development Center and will meet 5 days a week from 7:45 to 2:45. Students will work with like-minded children in an accelerated, discovery-based program that will allow your child to develop strong social and academic skills. Students accepted into this program will then be eligible for our self-contained, double-accelerated gifted/talented program in kindergarten at our new, state-of-the-art Bridges Elementary School. A Stanford Binet IQ test score of 130 required for acceptance.

ENROLLMENT PROCEDURES

Registration for the 2017-2018 Brilliant Beginnings and Kindergarten Prep programs begins January 16, 2017, for previously enrolled families and HUSD employees. Open registration begins January 23 for new families. We encourage you to register early. We will accept registrations daily at our preschool campuses.

PROGRAM LOCATIONS

North Campus -Elona P. Cooley Early Childhood Development Center located at 1100 S. Recker Road, Gilbert, AZ 85296. Phone 480-279-8400.

South Campus -Sue Sossaman Early Childhood Development Center located at 18655 East Jacaranda Blvd., Queen Creek, AZ 85142. Phone 480-279-8600.

Items needed for registration:

Completed Registration Form – This form must be filled out entirely for registration to be accepted. Please note that we will not be able to accept partially competed paperwork at registration. (The registration forms are available online and at each preschool location.)
A Non-Refundable Registration Fee - $75.00 per child is due at registration to finalize your child’s placement in the program.
Emergency Information and Immunization Record – It is the parent’s responsibility to make sure that the information provided on the Emergency Information and Immunization Record is kept current. It is extremely important that all home, business, and emergency contacts are correct and COMPLETE. At least 2 local emergency contacts, in addition to the parents/guardians, must be listed on this form. No one may pick up your child unless they are listed on this card.
Proof of Current Immunizations – Your child’s immunization records will be reviewed by the school nurse. The Department of Health Services requires that the immunization record provided by a parent from a health care provider contain all current, age-appropriate immunizations. If a child’s immunizations are not up to date, they will not be allowed to attend either program until the parent/guardian brings an updated immunization record.

Copy of Child’s Birth Certificate – Please provide a copy of your child’s birth certificate.
Copy of your driver’s license and proof of residency - utility bill or see registrar for acceptable options.

PROGRAM OPTIONS AND TUITION

All classes will follow HUSD school calendar year. Before and after school care is provided by Kids Club and will be available beginning at 6 a.m. until morning classes begin and after our p.m. programs ending at 6 p.m. There will be no school for preschool students on Professional Development days.This allows our teachers to have training and preparation time one day per month. These dates will follow the Professional Development dates for our district and are found on the 2017-2018 district calendar at

Brilliant Beginnings- Three and Four year olds.Must be 3 years old and potty trained.

Tuesday/Thursday Classes

Half Day Sessions: 8:15-11:15 A. M. or 12:15-3:15 P.M. $125 per month

Full Day Session: 7:45 A.M. - 2:45 P.M. $230 per month

Monday/Wednesday/Friday Classes

Half Day Sessions: 8:15-11:15 A.M. or 12:15-3:15 P.M. $165 per month

Full Day Session: 7:45 A.M. - 2:45 P.M. $345 per month

Monday - Friday Classes

Half Day Sessions:8:15-11:15 A.M. or 12:15-3:15 P.M.$300 per month

Full Day Session:7:45 A.M. - 2:45 P.M.$575 per month

Kindergarten Prep, Mandarin, Spanish, Highly Gifted- Four and Five year olds.

Monday - Friday Classes

Half Day Sessions:8:15-11:15 A.M. or12:15-3:15 P.M.$300 per month

Full Day Session:7:45 A.M. - 2:5 P.M.$575 per month

*Parents wishing to enroll their 4 or 5 year old in a 2 or 3 day program, will be placed in an appropriate Brilliant Beginnings class

LUNCH OPTIONS FOR FULL DAY STUDENTS

Full day Brilliant Beginnings and Kindergarten Prep students have the option to purchase a lunch each day or bring their own from home. Parents can put money in an online account once school has started. You will need your child’s student ID number and you can obtain that from their teacher or the school secretary. Parents may also complete a free and reduced meal form that will be available online at mymealtime.com or husd.org at the beginning of July, 2017. Please check the HUSD website for current lunch prices and menus.

PAYMENT OPTIONS

You may pay your tuition by mail, phone, online (you will be sent a password after your registration is processed) or in person at:Community Education HUSDLocated at the District Office2935 S. Recker Rd.

Gilbert, AZ 85295480-279-7055

Payment Schedule:THE FIRST MONTH’S TUITION FOR THE 2017-2018 SCHOOL YEAR IS DUE ON JULY 1, 2017. The remaining tuition is paid monthly beginning on Sept 1 and your last payment due on May 1.For your convenience, the total annual tuition is divided into 10 equal payments. Payments are due by the first day of each month. A late fee of $25.00 will be assessed after the fourth day of each month. For example, if your child is attending 5 half days with a tuition payment of $300, your first payment of $300 is due by July 1st. Late payment will be assessed on July 5th with the payment and late fee totaling $325.00. Please note that NO monetary credit will be given for unused, sick or vacation days.

Payments must be made before 4:00 p.m. on the due date. Payments collected the following day will be assessed a late fee.

REFUND POLICY

Brilliant Beginnings and Kindergarten Prep programs have a non-refundable monthly tuition policy. The Program Director and the Community Programs Supervisor may process a refund under extenuating circumstances.

**For additional information, please contact either the Elona P. Cooley Early Childhood Development Center at 480-279-8400 or the Sue Sossaman Early Childhood Development Center at 480-279-8600.

Revised 1-3-2017

HigleyUnifiedSchoolDistrictStudentEnrollmentForm

2935SouthReckerRoadGilbert,Arizona85295

(480)279-7000

STUDENTINFORMATION

ForOfficeUseOnly

COOLEYEARLYCHILDHOODDEVELOPMENT CENTERSPEDPEERSOSSAMANEARLYCHILDHOODDEVELOPMENTCENTER

StudentID #SAIS ID #

TeacherReceivedby:

GradeEntryCodeEntryDate

Date Enteredin GenesisInput By

Birth CertificateImmunizationsProofof ResidencyParent IDPHLOTE Custody/Guardian PapersDate RecordsRequested

Open Enrollment–InDistrictOpen Enrollment–Out of District

PleasePRINTyourchild’snameasitappearsonthelegaldocumentationrequiredforenrollment.

LegalLastNameLegalFirstNameLegalMiddleNameSuffix

GradeGenderNickNameLastNameGoesByBirthDate(mm/dd/yyyy)

Male
Female

Birth StateBirth CountryStudent’s Email AddressMother’sNameonBirthCert.

WhatistheprimarylanguageusedinthehomeregardlessoftheEnglishSpanishOtherlanguagespokenbythestudent?
Whatisthe languagemostoftenspokenbythe student?EnglishSpanishOther
Whatisthe languagethatthestudentfirstacquired?EnglishSpanishOther

The U.S. Departmentof Education requiresallstatestocollectraceand ethnicity information on studentsandstaff.

Ethnicity(Mustselectone):

No,notHispanic/Latino / Yes,Hispanic/Latino
Race(Mustselectoneormore)
BlackorAfricanAmerican / White / Asian
AmericanIndianorAlaskanNative / NativeHawaiianorotherPacificIslander

Student’sHomeAddressStudent’sMailingAddress(ifdifferent)

CityStateZipCodeCityStateZipCode

Student’sPrimaryHomePhoneStudent’sSecondaryHome PhoneSubdivision

DwellingTypeSingleFamily(House)ApartmentMobile HomeTrailer

Lastschoolattended(including HUSDschools)Addressoflastschoolattended(includingHUSDschools)EnterWithdrawDates

Mystudentiscurrentlyonlong-termsuspensionorexpulsionfrom anotherschooldistrictYesNo

REQUIREDDOCUMENTATION: A birth certificate or other reliable proof of thestudent’s identity orage,immunization recordsandproofof residencyare required forenrollment purposes.FailuretocomplywithARS 15-821, ARS 15-828,and ARS 15-872

HouseholdInformation

PARENT/GUARDIAN INFORMATION

StudentliveswithBothparentsMotherFatherGuardianFosterOther Custodyofstudent Joint Mother Father State Temporary Other
CustodypapersNon-custodial restrictions
NOTE: The school willnot honor a request ofrestrictions unless copiesof court orders supporting the r with the school. Apower ofattorney document cannot replacecourt-ordered custody papers.
equestare onfile

Parent/Legal Guardian#1Parent/Legal Guardian#2

LegalName (First, Middle,Last, Suffix (Pleaseprint clearly)LegalName (First, Middle,Last, Suffix (Pleaseprint clearly)

Relationshipto StudentRelationshipto Student

Home AddressHome Address

City, State,ZipCity, State,Zip

Mailing Address

(if different)

Mailing Address

(if different)

City, State,ZipCity, State,Zip

HomephonePrimary numberHome phonePrimary number

Cell phonePrimary numberCell phonePrimary number

WorkphonePrimary numberWorkphonePrimary number

EmailaddressEmailaddress

Currently servesinuniformedservices,incl.NationalGuard and Reserves.

Pleasedo notsendmeSchoolorDistrictinformation viaemail. Pleasedo notsendmeSchoolorDistrictinformation viaemail.

PLEASE LIST ALL CHILDREN OF SCHOOLAGEAND YOUNGER RESIDINGIN THE HOME (OLDEST FIRST)

First,Middle, Last Name,SuffixGenderBirth DateGradeSchool Name (ifattending)

Male
Female
Male
Female
Male
Female
Male
Female

EMERGENCY CONTACTS (Persons tocontact, other than parent,if child becomes ill)

First,Middle, Last NameRelationshipto Student

Home PhoneWorkPhoneCell PhonePriority

Ihereby affirm,bymy signature,thatIameither theparentorguardianof theabovenamedstudent (orthestudentifover 18) andthat all informationprovidedistrue, accurate andup-to-date.Any false statement subjects the above namedstudent to immediate withdrawal.Also,I hereby grantthe Higley UnifiedSchoolDistrict staff permission,inanemergency,totakemy childtotheclosest emergency center for treatment inthe eventthatI cannot bereached.It isunderstoodthat the nurse will try toreachthe parent(s) andotherpersons listedabove before arrangingfortransportationtoanemergency facility.

Parent/Guardian (Studentif over 18) SignatureDate

Rev04/15/2016Page 2 of4

HigleyUnifiedSchoolDistrictStudentEnrollmentForm

2935SouthReckerRoadGilbert,Arizona85295

(480)279-7000

SUPPORTPROGRAMS

PLEASESELECTSCHOOLPROGRAMCOOLEYPRESCHOOL

BBT/THM/W/FM-FKINDERPREP

SOSSAMANPRESCHOOL

BBT/THM/W/FM-FKINDERPREP

Thisinformationwillbekeptconfidentialandwillbeusedonlytoidentifystudentsfor supportservices.

Student NameStudentIDBirthDate

Questions1.and1a.areintendedtoaddresstheMcKinney-VentoAssistanceAct,U.S.C.A.42section11302(a).Youranswerswillhelpusdetermineresidenceinformationnecessaryforpotentialservicesforthisstudent.

1.Whereistheenrollingstudentpresentlyliving?(Checktheoneboxthatapplies)Inanemergencyshelter.

Inamotel,car,park,camperorcampsite.Withanotherfamilyinahouseorapartment,

Withfriendsorfamilymembersotherthanparent/guardian.Awaitingfostercareplacement.

Noneoftheabove.Youdonotneedtoanswerquestion1a.Pleasegotoquestion2.

1a.Thestudentliveswith:

OneParentTwoParents

OneParentandanotheradultthatisnotthelegalguardian

Arelative,friend(s)oranotheradult(s)Alonewithnoadults

Anadultthatisnottheparentorlegalguardian

2.
2a. / Yes / No / Haveyouoranymemberofyourhouseholdmovedinthepast3yearsforthepurposeor
workinginagriculture-relatedjobssuchasfieldwork,fruitorvegetablepackingcompanies,dairiesorranches?
Yes / No / Hasthestudentbeenpreviouslyenrolledinamigrantchildeducationprogram?
3. / YesNo / IfthechildwasbornoutsideoftheUnitedStates,hasthestudentattendedU.S.schoolsfora
totalofmorethan3academic years?
IfyouansweredNO, whatisthedatethestudentfirstenrolledinaU.S.School?
4. / YesNo / IsthestudentNativeAmerican?
IfYES,nameofTribe / Tribalnumber
5. / YesNo / Isthestudentunderrefugeestatus?
If YES,CountryI-94Number

Parent/GuardianName(pleaseprint)

Signature ofparentorguardianDate

HigleyUnifiedSchoolDistrictStudentEnrollmentForm

2935SouthReckerRoadGilbert,Arizona85295

(480)279-7000

SpecialEducation,504andGiftedProgramServicesInformation

PLEASESELECTSCHOOLPROGRAMCOOLEYPRE-SCHOOL

BBT/THM/W/FM-FKINDERPREP

SOSSAMANPRE-SCHOOL

BBT/THM/W/FM-FKINDERPREP

Student NameStudentIDBirthDateGrade

WelcometoHigleyUnifiedSchoolDistrict.Inordertoassistusinmeetingtheeducationalneedsofyourchild,please readbelowandsupplytherequestedinformationtotheextentyouareable.TherearemanyregulationsthatgovernSpecialEducation,studentsreceiving504accommodationsandservicesforgiftedstudents.Servicesprovidedbyyourchild’spreviousschoolshouldcontinue,butHUSDmustbeprovidedwithproperdocumentation.(Pleaseunderstandthatnotalldocumentationfromthepreviousschoolisautomaticallyforwardedinatimelymanner.)Ifyouwantyourchildtoreceivetheappropriateservices,pleasesubmitcurrentreports,evaluations,individualizedEducationProgram(IEP’s)andotherinformation youmayhaveregardingyourchildassoonaspossible.Youreffortwillexpediteservices.Thankyoufortakingthetimetoprovidethisvaluableinformation.

SERVICES/PROGRAMS

Pleasecheckallprogramsthatstudenthasbeenenrolledin:

Special Education with IEPTitleIReading

SpeechTherapyTitleIMath

OT/PTOther

ELLProgram

504SERVICES

YesNoDidyourchildreceiveaccommodationsundera504plan?

IfYES,pleaseindicatethedisabilityforwhichthechildhada504plan:

Nameofdiagnosingphysician:

YesNoDoyouhaveacopyofthephysician’sstatementorreport?

IfYES,pleaseprovideacopy

GIFTEDPROGRAMSERVICES
YesNo / DidyourchildreceiveGiftedandTalentedServices(GATE)atthepreviousschool?
Pl / easedescribetheservicesprovidedtoyourchild:

Parent/GuardianName(pleaseprint)

SignatureofparentorguardianDate

Stateof Arizona

DepartmentofEducation

OfficeofEnglishLanguageAcquisitionServices

Primary Home Language Other Than English (PHLOTE)

Home Language Survey

(Effective April 4, 2011)

These questionsareincompliance withArizonaAdministrativeCode, R7-2-306(B)(1), (2)(a-c).

Responses to these statements will be used to determine whether the student will be assessed for English Language Proficiency.

1.Whatistheprimarylanguageusedinthe homeregardlessofthelanguagespoken by the student?

2.What is the language most often spoken by the student?

3.What is the language that the student first acquired?

Student NameStudent ID

Date of BirthSAIS ID

Parent/Guardian SignatureDate

District or Charter

School

------

Please providea copy of theHome Language Survey tothe ELL Coordinator/Main Contact on site. InSAIS,please indicate the student’s homeor primary language.

Estado deArizona

DepartamentodeEducaciónServiciosdeAprendizajedelInglés

Idioma Principalen elHogarexcluyendo elinglés (PHLOTE)

Encuestasobre elIdiomaen elHogar

(Efectivoel4deabrilde2011)

Preguntasenconformidad conR7-2-306(B)(1), (2)(a-c)del Reglamento de la Junta Directiva.

Lasrespuestasqueproporcionea laspreguntassiguientesseránusadas para determinarsi se evaluarálacompetenciaenelidiomainglés desuhijo(a).

1.¿Cuálidioma se hablaprincipalmenteensuhogar sin considerar el idiomaquehabla el estudiante?

2.¿Cuálidiomahabla el estudianteconmayorfrecuencia?

3.¿Cuálfueelprimeridiomaqueaprendió el estudiante?

Nombre del estudianteNúm.deidentificación

Fecha de nacimientoNúm.de SAIS

Firma del padre o tutorFecha

Distrito o Charter

Escuela

------

Please providea copy of theHome Language Survey tothe ELL Coordinator/Main Contact on site. InSAIS,please indicate the student’s homeor primary language.

Arizona DepartmentofEducation Arizona Residency DocumentationForm

StudentSchool

SchoolDistrictorCharter Holder

Parent/LegalGuardian

AstheParent/LegalGuardianoftheStudent,IattestthatIamaresidentoftheStateofArizonaand submitinsupportofthisattestationacopyofthefollowingdocumentthatdisplaysmynameand residentialaddressorphysicaldescription of the propertywherethestudentresides:

Valid Arizona driver’slicense, Arizona identificationcardormotorvehicleregistration

ValidU.S.passport

Realestatedeedormortgage documents

Propertytaxbill

Residential leaseorrentalagreement

Water,electric, gas, cable,orphone bill

Bankorcreditcard statement

W-2 wage statement

Payrollstub

Certificate oftribalenrollmentorotheridentification issued bya recognized Indian tribethat containsan Arizona address.

Documentation froma state, tribalorfederalgovernmentagency(SocialSecurityAdministration,

Veteran’s Administration,Arizona DepartmentofEconomic Security)

Iamcurrentlyunableto provide anyofthe foregoingdocuments.Therefore, Ihave provided an originalaffidavitsignedand notarized byan Arizona residentwho atteststhatIhave established residencein Arizona with the personsigningtheaffidavit.

Signature ofParent/Legal GuardianDate

StateofArizona AffidavitofSharedResidence

IswearoraffirmthatIama residentofthe State of Arizona andthatthe personslisted belowreside with me atmyresidence, described asfollows:

Persons whoreside with me:

Location ofmyresidence:

Isubmit in supportof this attestation acopyofthefollowingdocument thatdisplaysmyname and current residence address orphysicaldescriptionofmyproperty:

Valid Arizona driver’slicense, Arizona identificationcardormotorvehicleregistration

ValidU.S.passport

Realestatedeedormortgage documents

Propertytaxbill

Residential leaseorrentalagreement

Water,electric, gas, cable,orphone bill

Bankorcreditcard statement

W-2 wage statement

Payrollstub

Certificate oftribalenrollmentorotheridentification issued bya recognized Indian tribe.

Documentation froma state, tribalorfederalgovernmentagency(SocialSecurityAdministration, Veteran’s Administration,Arizona DepartmentofEconomic Security)

Printed Name ofAffiant:

Signature ofAffiant:

State ofArizona

Countyof

Acknowledgement

Theforegoingwas acknowledged before me thisdayof,20, By.

MyCommission Expires:

NotaryPublic

HigleyUnifiedSchoolDistrict2935SouthReckerRoadGilbert,Arizona85295

(480)279-7000

MEDICALHISTORY

Student Name (LegalLast,First, andMiddle Names)BirthDate

Doesyourchildtakeanymedicationsonaroutinebasis?YesNoDuringschoolhours?YesNo

NameofmedicationPurposeofmedication Nameofmedication Purposeofmedication

Pleasecontacttheschoolhealthofficeregardingthepoliciesformedication(s)takenduringschoolhours.

HEALTHCONDITIONS(checkallthatapply)

ADD/ADHD / CYSTICFIBROSIS / HEARINGAIDS
ALLERGIES(LIFETHREATENING) / DEVELOPMENTALDELAY / HEARINGIMPAIRED
ASTHMA / DIABETES / HIGHBLOODPRESSURE
BEHAVIORAL/EMOTIONAL / EATINGDISORDER / PSYCHOLOGICAL
BLOODDISORDERS / ENDOCRINEDISEASE / SEIZUREDISORDER
BRAIN/CNSDISORDER / ENVIRONMENTAL/ALLERGIES / TRACH/G-TUBE/O2
CANCER / GENETICDISORDER / URINARY/KIDNEY
CARDIOVASCULAR / G.I.DISORDER / VISUALLYIMPAIRED
CEREBRALPALSY / HEADACHES / OTHER

PLEASEFULLYEXPLAINANYANSWERSCHECKEDABOVE:

FOODALLERGIES

YesNoWHATFOODS?Yes NoEPI PENNEEDED* Yes NoBENADRYLNEEDED*

*PLEASEBRINGTHESEITEMSTOTHEHEALTHOFFICETOSIGNIN

Pleaselistanyotherconcerns,surgeries,illnessesoraccidentsinthepastyear:

CHICKENPOX(VARICELLA)STATUS

Beginningwiththe2011schoolyear,studentsenteringpreschool,kindergartenandallothergradeswillberequiredtohaveproofofreceivingthechickenpoxvaccination(Varicella)orahistoryofhavingthechickenpoxdisease.

YES,mychildhashadthechickenpoxdisease.Month and year of disease YES,mychildhashadthechickenpox vaccine. Date of vaccine NO,mychildhasneverhadtheillnessorvaccineforchickenpox.

Childrenmusthaveproofofallrequiredimmunizations,orvalidexemption,inordertoattendschool.Ifyourchild’simmunizationsarenotcurrent,pleasecontacttheschoolhealthofficeforalistoffreevaccinationclinics.

CDC/SGH# or name:

Arizona DepartmentofHealthServices Bureau ofChild CareLicensing

Emergency,InformationandImmunizationRecordCard

Child’sName: / DateEnrolled: / Updated:
HomeAddress(#,Street,City,State,ZipCode): / DateDisenrolled:
HomePhone: / DateofBirth: / Sex:malefemale
MotherorGuardianName: / HomeAddress (#,Street,City,State,Zip Code):
Cell Phone (optional): / ContactTelephoneNumber:
FatherorGuardianName: / HomeAddress (#,Street,City,State,Zip Code):
Cell Phone (optional): / ContactTelephoneNumber:

IauthorizethefollowingindividualstocollectmychildfromthefacilityincaseofemergencyorifIcannotbecontacted:(PursuanttoR9-5-304.B,atleasttwocontactpersonsarerequired.)

Name: / Contact TelephoneNumber:
Name: / Contact TelephoneNumber:
Name: / Contact Telephone Number:
Name: / Contact Telephone Number:

IfMedicalcareis necessary, call:

Health Care
Provider* / Name: / Contact TelephoneNumber:

*A Health CareProvideris a physician, physicianassistant or registered nursepractitioner.

Incaseofinjury orsuddenillness, I requestthatthisindividual becalledfirst:

The followingindividual(s)mayNOTremovemychild from the facility: