Toddlers and Crawlers Class

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Birthday *

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Parent 1 Name *

Parent 1 Phone *

Parent 1 Email

Parent 2 Name

Parent 2 Phone

Parent 2 Email

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February 28th - March 28th

• 9:15 - 10:15 Cost: $125.00

Check boxes below to indicate if your child has any allergies, special needs/services, or medical conditions:

• Allergies
• Asthma
• Medical Conditions
• Special Education
• Occupational/ Physical Therapy
• Speech/Language Delay

Agreements

• I understand my child may not attend class if he/she has one or more of the following symptoms. Fever over 100.4, vomiting, diarrhea, undiagnosed rash, has started antibiotics in the past 24 hours, congestion/coughing. We kindly ask that you keep sick children home for minimum of 24 hours.

Agreements

• I understand that I am responsible for ensuring my child is covered by health insurance and that any injury or illness incurred at class is the financial responsibility of the parent and not that of The Country School.

Agreement

• I give my permission for my child’s photograph to be used on social media or for advertising purposes

Agreements

• Arrival/Dismissal- Please do not arrive at class earlier than the scheduled time. Parent or caregiver will stay for the duration of the class.

Agreements

• I give permission for my contact information to be shared with other class parents.

Emergency Contacts/Approved Pick-Up Contacts Other Than The Parent *

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Emergency Contacts/Approved Pick-Up Contacts Other Than The Parent

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Emergency Contacts/Approved Pick-Up Contacts Other Than The Parent

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