Hajja’s House A Place Where Young Minds Grow!

START DATE

Date

WITHDRAW DATE

Date

Child's Name

Child's Age

Date of Birth

Date

Sex

Male Female

Parent's Mom/Guardian's Name

Parent's Dad/Guardian's Name

Work Phone

Email Address

example@example.com

City, ST ZIP Code

Primary Emergency Contact

Secondary Emergency Contact

Cell Phone

Address

Physician's Name

Hospital/Clinic Preference

Phone Number

Insurance Company

Policy Number

Allergies/Special Health Considerations

I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency.

Parent's/Guardian's Signature

Clear

Date

Child's Name

Does your child have any special learning, speech, physical or behavioral matters? If yes, please explain below.

Yes No

My child has the following special learning, speech, physical or behavioral matters:

Child lives with (Please check all that apply):

Father Mother

I authorize the following to pick up my child(ren) in my absence

Person 1: Name

Relationship to child

Phone number

Address

Person 2: Name

Relationship to child

Phone number

Address

Signature

Clear

Final drop off and pick up times are to be assigned at Orientation. Please list your preference for consideration.

Enrollment Staus*

Full time Part time (minimum of 2 days)

If part-time, please select days of care

Drop off time:

Pick up time:

Is your child toilet trained?*

Yes No

What are the most important qualities you are looking for in a primary school/after school program for your child?

I understand that Hajja’s House Global Learning Center is required by Georgia State Law to report all Cases of child abuse [that are stated] must be reported to the Child Protective Services Department.

Parent Signature

Clear

Date

Due to Covid - 19 Field trips will be suspended for the first semester or until further notice.

All children are involved in daily trips outside of their classrooms. This includes going to the school's playground, going on nature walks, and walking in the neighborhood.

Please sign below, acknowledging permission for your child to attend field trips in the Center's neighborhood.

Parent Signature

Clear

Occasionally, we may photograph the children while they are in their classrooms, on field trips or during activities.

Photographs may be shared with other parents or used on the Hajja’s House website and Facebook page for publicity purposes.

Please check the appropriate box below, indicating whether or not you give your permission for us to photograph your child.

I give permission for my child to be photographed while at Hajja's House

Yes No

Parent Signature

Clear

Date

Islamically Sound, Montessori Inspired Global Learning Center

Hagar's Preschool Application

Alternative Emergency Contacts

Medical Information

ADMISSIONS APPLICATION PART II

AUTHORIZATION FOR PICK-UP

Parent Signature

GENERAL INFORMATION

CHILD ABUSE REPORTS

FIELD TRIPS OFF PREMISES

FIELD TRIPS IN THE CENTER’S NEIGHBORHOOD

PERMISSION TO PHOTOGRAPH