LLL PRESCHOOL

Child Face Sheet/Enrollment Form

Child’s Name _________________________________	Sex: M F	Skin Color _____________

Home Address ________________________________	Height __________	Eye Color _____________

City/State/Zip ________________________________	Weight __________	Hair Color _____________

Home Telephone __________________ Primary Language____________	D.O.B. ____/____/____

Identifying Marks ________________________________________Date of Admission ____/____/____

Allergies_________________________________________________________________________________

If your child has allergies, are any life threatening? Yes/No. *Individual Health Plan if Yes.

If yes, which ones? _______________________________________________________________________

Chronic Health Concerns ________________________________________________________________

Current, regular medications _____________________________________________________________

Special Limitations or Concerns ___________________________________________________________

PARENT/GUARDIAN INFORMATION

Parent/Guardian Name ____________________	Parent/Guardian Name __________________

Relationship to Child _______________________	Relationship to Child _____________________

Address (if different) ________________________	Address (if different) ______________________

____________________________________________	__________________________________________

Home Telephone ___________________________	Home Telephone ________________________

Cell ________________________________________	Cell _____________________________________

E-mail Address ______________________________	E-mail Address ___________________________

Business Name ______________________________	Business Name ___________________________

Business Telephone __________________________	Business Telephone _______________________

Days/Hours at work __________________________	Days/Hours at work ______________________

List the names of people who have permission to pick up your child from LLL Preschool for non-emergency, routine picks-ups in the event that a parent/guardian is unable to receive your child.

________________________________________________	_________________________________	_____________________________________________

Name	Phone number	Relationship

________________________________________________	_________________________________	_____________________________________________

Name	Phone number	Relationship

LLL PRESCHOOL

First Aid and Emergency Medical Care

Child’s Name ___________________________________________________	D.O.B. ____/____/____

Child’s Physician/Practice Name _________________________________________________________

Address __________________________________________________	Telephone ___________________

I authorize the staff members of LLL Preschool, who are trained in the basics of First Aid, to administer First Aid to my child when appropriate.

I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, if I cannot be reached, I hereby authorize LLL Preschool to transport my child to the __________________________ hospital (or nearest hospital) to secure necessary medical treatment for my child.

________________________________________________	____________________________________

Signature of Parent/Guardian	Date

EMERGENCY CONTACTS

Please list three persons who are familiar with your child and are able to act on your behalf in a medical or other emergency. Local or in-area persons are requested. Persons listed will be contacted in the order listed.

Name ________________________________________	Relationship to child ______________________

Address ______________________________________	Home Phone ____________________________

Work Phone __________________________________	Other Phone _____________________________

Name ________________________________________	Relationship to child ______________________

Address ______________________________________	Home Phone ____________________________

Work Phone __________________________________	Other Phone _____________________________

Name ________________________________________	Relationship to child ______________________

Address ______________________________________	Home Phone ____________________________

Work Phone __________________________________	Other Phone _____________________________

I hereby give my permission for my child to be released from the program and/or to be received at the end of the program to the above persons. This could include relieving LLL Preschool staff at an emergency medical facility and making treatment decisions.

________________________________________________	____________________________________

Signature of Parent/Guardian	Date

LLL PRESCHOOL

First Aid/Emergency Medical Authorization Form

Child’s Name ___________________________________________________	D.O.B. ____/____/____

This form serves to outline the First Aid and emergency medical procedures for LLL Preschool. All staff are required to have current First Aid certification: based on this training, the first step for each procedure will be for the staff to evaluate the situation at hand and proceed as deemed appropriate.

PROCEDURE: MINOR FIRST AID TREATMENT

LLL Preschool staff will administer treatment

Parent/guardian will be informed on the same day

PROCEDURE: SECONDARY FIRST AID TREATMENT

Parent/guardian or designee will be called immediately

If above unavailable, LLL staff will proceed with basic first aid while simultaneously contacting emergency medical professionals to proceed under their instructions

LLL Preschool staff will accompany child to emergency facility and remain until relieved.

PROCEDURE: CRITICAL MEDICAL EMERGENCY

LLL Preschool staff will administer First Aid/CPR and immediately contact emergency medical professionals for assistance and instructions

While step one is in progress, LLL Preschool staff will contact parent/guardian or designee.

LLL Preschool staff will accompany child to emergency facility and remain until relieved.

The staff at LLL Preschool has my permission to administer First Aid treatment and CPR or seek professional medical treatment for my child. I understand that the staff will make every effort to contact me or my designated emergency contacts and that my child will be accompanied and supervised by LLL Preschool staff in the event that transport to a medical facility is necessary.

________________________________________________	____________________________________

Signature of Parent/Guardian	Date

Health Insurance Co.	Policy #

Parent(s) Name(s):	Phone (c)

LLL PRESCHOOL

Developmental History and Background Information

Child’s Name ___________________________________________________	D.O.B. ____/____/____

DEVELOPMENTAL HISTORY

Any speech difficulties? __________________________________________________________________

Special words to describe needs __________________________________________________________

Ability to help/care for self without assistance______________________________________________

HEALTH

Any known complications at birth? _______________________________________________________

Any serious illnesses and/or hospitalizations? _______________________________________________

EATING HABITS

Special characteristics or difficulties? ______________________________________________________

Favorite foods: _______________________________ Foods refused: _____________________________

Child eats with ___hands ___spoon ___fork

TOILET HABITS

Is your child potty trained? _______________________________________________________________

How does your child indicate bathroom needs (special words)? ____________________________

Is your child ever reluctant to use the bathroom? __________________________________________

Does your child have accidents? _________________________________________________________

SLEEPING HABITS

Does your child become tired or nap during the day (include when and how long)? ________

__________________________________________________________________________________________

What time does your child go to sleep at night? ___________________________________________

What time does your child get up in the morning? _________________________________________

SOCIAL RELATIONSHIPS

How would you describe your child? ______________________________________________________

_______________________________________________________________________________________________________________________________________

With whom does your child play regularly? ________________________________________________

(Social Relationships continued)

Child’s Name ____________________________________________________________________________

Previous experience with other children/day care: _________________________________________

Reaction to strangers: ____________________________________________________________________

Able to play alone? __________	Favorite toys/activities: _____________________________________

Fears (the dark, animals, etc.): ____________________________________________________________

Relevant preferences/disposable comfort items: __________________________________________

How do you comfort your child? __________________________________________________________

What method of behavior management/discipline do you utilize at home? _________________

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

What would you like your child to gain from this child care experience? ____________________

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

Is there anything else you would like us to know about your child? __________________________

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

________________________________________________	____________________________________

Signature of Parent/Guardian	Date

LLL PRESCHOOL

Photography/Class List Permission Form

Child’s Name ____________________________________________________________________________

PHOTOGRAPHY

The Commonwealth of Massachusetts requires written consent by a parent/guardian for activities involving publicity. Publicity includes photographs and participation in the mass media.

Photography of LLL Preschool activities occasionally occurs in the local/area newspapers. Photographers may take photos of field trips or other special/daily activities.

By signing below, the parent/guardian grants permission for the child indicated to be photographed while participating in LLL Preschool activities.

________________________________________________	____________________________________

Signature of Parent/Guardian	Date

CLASS LIST

In order to print your child’s name, address, telephone number, birthday, and the name of his/her parents/guardians on a class list, we must have written permission from a parent/guardian of the LLL Preschool student. The class lists will be distributed to each child in the class.

By signing below, the parent/guardian grants permission for the above information to be printed on a class list and distributed to the children in his/her child’s class.

________________________________________________	____________________________________

Signature of Parent/Guardian	Date

LLL PRESCHOOL

Permission to Leave the Classrooms

Our licensing body, the Commonwealth of Massachusetts Office of Early Education and Care, requires us to obtain your written permission for your child to participate in activities that occur outside of our licensed classroom space. Those activities include occasional walks through the West Parish Garden Cemetery located opposite our building on Reservation Road, visits to the Children’s Garden opposite our playground, and monthly fitness and movement classes that are held upstairs in our building in the Fellowship Hall.

I give permission for my child to participate in the activities described above.

Child’s Name ____________________________________________________________________________

______________________________________________	_______________________

Signature of Parent/Guardian	Date

LLL PRESCHOOL

Permission to Send Information Via Email and Text

LLL Preschool teachers and the Board will need to communicate information such as reminders about upcoming events and activities to the families of our students. Please indicate below your willingness to receive school information, bulletins, and/or reminders via your email address or text messages. Should you choose not to have information sent, you will find LLL information in your child’s cubby and/or the main and class bulletin boards.

Child’s Name ____________________________________________________________________________

Yes, I do wish to receive information via email and text ____________________________________

No, I do not wish to receive information via email and text _________________________________

Preferred email address __________________________________________________________________

Preferred number for texts: _______________________________________________________________

______________________________________________	_______________________

Signature of Parent/Guardian	Date

THE COMMONWEALTH OF MASSACHUSETTS

Department of Early Education and Care

OFF SITE ACTIVITIES PERMISSION FORM

LLL Preschool

Section 1 - Program completes prior to parental consent

Program: LLL Preschool

Name of Educator(s) responsible for child: LLL Preschool Teachers

Name of off-site location and address: West Parish Children’s Garden and Cemetery

Date of off-site activity: 9/2026-6/2027 Time Leaving/Returning to Program: Between 8:40-2:30

Method of Transportation: Supervised Walk Fee associated with activity (if any): None

**NOTE** Each child must carry on his/her person the name, address, and telephone number of staff or child care program whenever she/he is off the premises in care of the program.

Section 2 – Parent/Guardian completes prior to off-site activity

I give permission for my child to attend the above identified off-site activity Child’s Name: ______________________________ Child’s Date of Birth: _______________________________ Parent’s/Guardian’s Name: _____________________________ Phone Number: _________________________ I authorize child care program staff to secure necessary emergency medical treatment Name of child’s Physician, Address, phone number: ________________________________________________ _____________________________________________________________________________________________ Child’s allergies, health conditions, or Individual Health Plan: ________________________________________ _____________________________________________________________________________________________ Health Insurance Plan and Policy #: ______________________________________________________________ Emergency Contact Name: ________________________________ Contact #: ____________________________ ______________________________________________ ______________________ (Parent/Guardian Signature) (Date)

This form must accompany each child on the off-site activity

SG/LG/SAOffSitePermission20100122

LLL PRESCHOOL

Cancellation and Refund Policy

Child’s Name ____________________________________________________________________________

Cancellations or changes in registration must be made in writing to LLL Preschool, 129 Reservation Road, Andover, MA 01810.

The application fee and the initial deposit made to reserve your child’s placement at LLL Preschool for the current school year are NON-REFUNDABLE.

After August 1st of the said year, students are considered enrolled for the remainder of the school year. In the event of voluntary withdrawal, tuition for the duration of the year remains the responsibility of the family, unless LLL Preschool is able to fill the opening.

Important: Refund of tuition or deposits will be made only in cases of certifiable illness subject to review and acceptance of the LLL Preschool Committee.

________________________________________________	____________________________________

Signature of Parent/Guardian	Date

LLL PRESCHOOL

Transportation Authorization Form

CHILD’S NAME:_________________________________________________________________________

MY CHILD WILL ARRIVE AT THE PROGRAM:	MY CHILD WILL DEPART FROM THE PROGRAM:

___Parent drop off	___Parent pick up

___Supervised walk	___Supervised walk

___Unsupervised walk	___Unsupervised walk

___Public/Private/Van	___Public/Private/Van

___Program Bus/Van	___Program Bus/Van

___Contract/Van	___Contract/Van

___Private trans. arranged by parent	___Private trans. arranged by parent

___Other	___Other

_________________________________________	______________________________________

Signature of Parent /Guardian	Date

Hand Sanitizer Permission Form

Child’s name:_________________________________________________________________________

☐ I give LLL Preschool permission to use hand sanitizer on my child’s hands.

☐ I do NOT give LLL Preschool permission to use hand sanitizer on my child’s hands.

Hand Sanitizer will be stored out of reach of all children.

The teacher will assist children with hand sanitizer.

Please do not send hand sanitizer in or attached to your child’s backpack or jacket.

Parent Signature _________________________________________________Date _____________