Application Child Information:Child's full name:* Child's nickname (name commonly used):* Date of Birth:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex:*MaleFemaleHome Address:*Child's nationality:Language(s) spoken at home:Desired Location*Upper East SideTribecaDesired Date of Entry*January 2017June 2017September 2017January 2018June 2018September 2018January 2019June 2019September 2019Desired program time*AMPMWhy do you want your child to attend Playgarden Prep? Are you familiar with the Montessori philosophy?*How did you hear about Playgarden Prep?We are Playgarden MembersFrom a friendHRP MamasOther online promotionPrint promotionOtherHave you ever been a Playgarden Class, Playground or Camp member?*YesNoParent/Guardian Contact Information:Relation to Child:*Full Name:* Email:* Home Number:Mobile Number:*Work Number:Relation to Child:Full Name: Email: Home Number:Mobile Number:Work Number:Emergency Contact:Relation to Child:*Full Name:* Email:* Home Number:Mobile Number:*Work Number:Caregivers/Additional Authorized Pick-Up:Full Name: Phone Number:Full Name: Phone Number:Full Name: Phone Number:Medical Information:Pediatrician:*Phone Number:*Insurance Company:*Does your child have any dietary restrictions or requirements? (if yes, please specify)*YesNoDietary restrictions or requirements.Does your child suffer from any known allergies? (if yes, please specify)*YesNoAllergiesDoes your child have any serious conditions in her/his medical history, for example asthma, diabetes, epilepsy, surgery? (if yes, please specify)*YesNoSerious conditions.Does your child have any special needs? Is there anything else we should know about your child?Personal Information:Does the applicant have siblings? If so, how many and what are their ages?*YesNoSiblings, how many, ages.Is your child supervised by adults other than parents? If so who and how often?*YesNoSupervised by other adults, who, how often.Does your child regularly socialize with other children? If yes, in what setting?*YesNoRegularly socialize with other children, and setting.What types of activities do you do together as a family?What are your child's favorite foods and regular meal times?What time does your child go to bed at night and wake up in the morning? What time does your child take a nap?Is your child potty-trained?*Yes, completelyWe're working on itNot yetHas your child ever been dropped off before? (if yes, please specify)*YesNoIs there anything else you would like us to know about your child or your family?Binding Agreement:I understand Playgarden Prep will take all necessary precautions to ensure the safety of my child and that the school cannot be responsible for any injury my child may incur while in attendance.* I agree I give permission for the staff of Playgarden Prep to administer first aid and/or CPR to my child.* I agree I give permission to the staff of Playgarden Prep to request medical assistance from the emergency section of the nearest hospital, if my child sustains an injury while in attendance at School, and I am unavailable or if the designated emergency contact person cannot be reached.* I agree I agree to all provisions in the Playgarden Enrollment Agreement (http://playgardennyc.com/enrollment-agreement/)* I agree Parent Signature:*Date:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920PhoneThis field is for validation purposes and should be left unchanged.