The Day School

Registration Form

Please fill out the following form to the best of your ability so we may have all the information we need to care for your child.

Step 1 of 3

Child Information

Child's Name(Required)

First Last

Nickname

if needed

Sex(Required)

Home Street Address(Required)

Street Address Address Line 2 City State ZIP Code

Date of Birth(Required)

Preferred Phone(Required)

Previous Child Day Programs Attended

if any

Desired Program:(Required)

Two-Year-Old (Tues/Thurs)

Three-Year-Old 2 Day (Tues/Thurs)

Three-Year-Old 3 Day (M/W/F)

Pre-K 4 Day (M-Thurs)

Junior Kindergarten 5 Day (M-F)

Chronic Physical Limitations/Pertinent Development Information/ Special Accommodations Needed:(Required)

Parent Information

Parent 1 Name(Required)

First Last

Email(Required)

Same Address as Child?(Required)

Yes

No

Parent 1 Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone (cell/work)(Required)

Place Employed(Required)

Parent 2 Name(Required)

First Last

Email(Required)

Same Address as Child?(Required)

Yes

No

Parent 2 Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone (cell/work)(Required)

Place Employed(Required)

Emergency Information

Allergies or Intolerance to Food, Medication, etc. and Action to Take in an Emergency(Required)

Child's Physician(Required)

Phone(Required)

Emergency Contacts

Contact persons in the event parent(s) cannot be reached. Please do not list parents as emergency contacts.

Emergency Contact 1 Name(Required)

First Last

Emergency Contact 1 Phone(Required)

Emergency Contact 1 Address(Required)

Street Address Address Line 2 City State ZIP Code

Emergency Contact 2 Name(Required)

First Last

Emergency Contact 2 Phone(Required)

Emergency Contact 2 Address(Required)

Street Address Address Line 2 City State ZIP Code

Person(s) authorized to pick up child.(Required)

Please list one per line.

Person(s) NOT authorized to pick up child.*(Required)

*Appropriate paperwork such as custody papers shall be attached if a parent is not allowed to pick up the child. NOTE: Section 22.1-4.3 of the Code of Virginia states that unless a court order has been issued to the contrary, the noncustodial parent of a student enrolled in a public school or day care center must be included, upon the request of such noncustodial parent, as an emergency contact for events occurring during school or day care activities.

Photo Release(Required)

At The Day School, we regularly document the students' work and activities using video and digital photography. Images may appear in private password-protected venues such as classroom videos and newsletters, or publicly in blog posts, advertising, and presentations. Should you have any objections to your child's image being featured privately or publicly, please note them below:

No objection

I do not wish my child’s photograph being used in private, password protected ways including a private, classroom specific photo sharing site

I do not wish my child’s photograph and/or name being used in public facing material advertising and the school's website.