Enrollment InformationStudents Name* Date of Birth* MM slash DD slash YYYY Address Street Address Home Phone*Gender*MaleFemaleMothers InformationMothers Name* Email Address* Address* Street Address City ZIP / Postal Code Home Phone*Cell Phone*Employers Name* Employers Address* Work PhoneDays & Hours Worked* Drivers License #* Marital Status*SingleMarriedDivorcedSeperatedFathers InformationMothers Name* Email Address* Address* Street Address City ZIP / Postal Code Home Phone*Cell Phone*Employers Name* Employers Address* Work PhoneDays & Hours Worked* Drivers License #* Marital Status*SingleMarriedDivorcedSeperatedEmergency Contact & Release PersonsName* Address* Street Address Home Phone*Physician's Name* Physician's Address* Street Address Work Phone*General Information and Policies(Please refer to parent handbook for a complete list of policies) In order to insure the welfare and safety of all of the students, customary and socially acceptable levels of behavior are required of all students. These expectations include but are not limited to the behaviors outlined in the behavior code for students given to you at time of registration. Peppermint stick staff will administer medication as laid down in our medication policies and procedures given to you at the time of registration. Peppermint Stick reserves the right to practice standard medical procedures, get emergency treatment, regardless of child’s religious background, in case of emergency. I give my permission for my child/children to ride in the center van/bus to or from Peppermint Stick. Peppermint Stick has my permission to take my child/children on fieldtrips. Parents will be notified of such trips in advance. I further give permission to Peppermint Stick to use any photographs of my child for display or publicity such photos and video will remain the property of Peppermint Stick. Days of attendance are established at the time of enrollment. Any changes including withdrawal from the program, requires a two week notice. I affirm that I/we agree to the policies in the parent handbook, policies such as guidance & discipline, tuition payments, centers pesticide policy etc. The Parent handbook is available on line at www.peppermintstickcc.com or you can request a paper copy. Schedule of AttendancePreschool Selection Preschool Preschool Days Monday Tuesday Wednesday Thursday Friday Kindergarten Selection Kindergarten Kindergarten Days Monday Tuesday Wednesday Thursday Friday Before School Selection Before School Before School Days Monday Tuesday Wednesday Thursday Friday Before & After School Selection Before & After School Before & After School Days Monday Tuesday Wednesday Thursday Friday Summer Camp Selection Summer Camp Summer Camp Days Monday Tuesday Wednesday Thursday Friday Other Selection Other Other Days Monday Tuesday Wednesday Thursday Friday Parent/Guardian Signature*Date* MM slash DD slash YYYY Please Type Name * A parent/legal guardian must fill out the registration form. If you are not a parent, proof of legal guardianship is required in writing.