Child *

First Name

Last Name

Child's birthdate *

MM

DD

YYYY

Gender

Male

Female

Home address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent 1 *

First Name

Last Name

Parent 1 Phone *

Best phone number to reach Parent 1

(###)

###

####

Parent 1 Business Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent 2

OPTIONAL

First Name

Last Name

Parent 2 Phone

Best phone number to reach Parent 2

(###)

###

####

Parent 2 Business Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Caregiver/Nanny

First Name

Last Name

Caregiver/Nanny Phone

Best phone number to reach Nanny/Caregiver

(###)

###

####

Release

Parents, do you authorize Prospect Preschool to release your child to this caregiver?

Yes

No

Convictions *

Have either parents or caregiver ever been convicted of a crime? (We ask this as parent involvement in the classroom is a requirement as a co-op preschool.)

Yes

No

Publicity Permission *

At Prospect Cooperative Nursery School, we welcome the opportunity to celebrate our students’ achievements and activities. The Information Age has provided additional mediums to publish these accomplishments, offering us new opportunities to showcase our programs and strengthen two-way communication. In order for Prospect to include a student, staff member or community member in printed publications, multi-media, social media or on the Internet, permission is needed. Our goal is to help promote the school and foster a sense of community, but we are sensitive to security concerns—children will not be tagged, nor will their images be used in paid advertising. We will also promptly remove any image if requested. "I give permission for my child’s image, and/or student work products to be utilized in various media forms including: newsletters, Prospect Cooperative web site and associated social media sites (images only), Prospect Cooperative print and digital production, print media (local newspapers and magazines), and future types of media." Please indicate whether you approve or disapprove:

Approve

Disapprove