The Premier School – Pickerington, OH

Family Registration

To register your family with The Premier School, you must complete the electronic form below or print and complete the PDF here.





Parent/Guardian Information

Mother/Guardian

First Name
M.I.
Last Name
Address
Occupation
Employed By
Work Address
Work Hours
Home Phone
Office Phone
Cell Phone
 
 Custodial Parent
Driver’s License #
Email
 
Preferred PIN number for checking in/out (4 digits, numbers only)
1st Choice
2nd Choice
Marital Status
 Married Single Divorced Separated Widowed Other:

 

Father/Guardian

First Name
M.I.
Last Name
Address
Occupation
Employed By
Work Address
Work Hours
Home Phone
Office Phone
Cell Phone
 
 Custodial Parent
Driver’s License #
Email
 
Preferred PIN number for checking in/out (4 digits, numbers only)
1st Choice
2nd Choice
Marital Status
 Married Single Divorced Separated Widowed Other:

 

Child Information

First Child

First Name
M.I.
Last Name
Name child prefers to be called
Grade/Class
Gender
Date of Birth
Child’s Address
List any existing medical conditions, medication and/or special attention your child may require?
Allergies
Pediatrician’s Name
Pediatrician’s Phone
Pediatrician’s Address
 
Has your child been enrolled in another licensed child care facility in the past 3 months?
 Yes No
If yes, then whom were you previously enrolled?
Photographs: May we take and maintain photos of your child for Parent Website Portal?
 Yes No

Second Child

First Name
M.I.
Last Name
Name child prefers to be called
Grade/Class
Gender
Date of Birth
Child’s Address
List any existing medical conditions, medication and/or special attention your child may require?
Allergies
Pediatrician’s Name
Pediatrician’s Phone
Pediatrician’s Address
 
Has your child been enrolled in another licensed child care facility in the past 3 months?
 Yes No
If yes, then whom were you previously enrolled?
Photographs: May we take and maintain photos of your child for Parent Website Portal?
 Yes No

Third Child

First Name
M.I.
Last Name
Name child prefers to be called
Grade/Class
Gender
Date of Birth
Child’s Address
List any existing medical conditions, medication and/or special attention your child may require?
Allergies
Pediatrician’s Name
Pediatrician’s Phone
Pediatrician’s Address
 
Has your child been enrolled in another licensed child care facility in the past 3 months?
 Yes No
If yes, then whom were you previously enrolled?
Photographs: May we take and maintain photos of your child for Parent Website Portal?
 Yes No

Fourth Child

First Name
M.I.
Last Name
Name child prefers to be called
Grade/Class
Gender
Date of Birth
Child’s Address
List any existing medical conditions, medication and/or special attention your child may require?
Allergies
Pediatrician’s Name
Pediatrician’s Phone
Pediatrician’s Address
 
Has your child been enrolled in another licensed child care facility in the past 3 months?
 Yes No
If yes, then whom were you previously enrolled?
Photographs: May we take and maintain photos of your child for Parent Website Portal?
 Yes No

 

Emergency Contacts & Authorized Pickup Persons

1st Contact/Pick Up

Name
Phone
Relationship to the Child
PIN for check in/out
(numbers only)
 
 Able to pick up all children in the family Not able to pick up the following children:

2nd Contact/Pick Up

Name
Phone
Relationship to the Child
PIN for check in/out
(numbers only)
 
 Able to pick up all children in the family Not able to pick up the following children:

3rd Contact/Pick Up

Name
Phone
Relationship to the Child
PIN for check in/out
(numbers only)
 
 Able to pick up all children in the family Not able to pick up the following children:

4th Contact/Pick Up

Name
Phone
Relationship to the Child
PIN for check in/out
(numbers only)
 
 Able to pick up all children in the family Not able to pick up the following children:

 

Tuition / Payment Information

Current Tuition Amount
 
 Weekly Bi-Weekly Monthly Other:
Please outline below whom is responsible for payment of tuition and fees. Please fill out if parents are divorced and split tuition payment or if tuition payment is the responsibility of an adult other than the parents listed above.

 

Additional Comments & Information

Is there is any other information that that would be helpful to our management and teaching staff?

 

I agree that all information in this form is accurate.
 

 

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