Noah’s Ark Registration Form – Noah's Ark Preschool Destin

Franz, Age 5

Registration for Noah’s Ark Preschool & Toddler Program – only fill out this form if your child has already been accepted. Looking to apply? Fill out our application first.

250 Indian Bayou Trail Destin, Florida 32541
Charlene Robertson, Director 850-650-3504
License Number CO1Ok0094

A $100 Registration Fee is Due with this form. You can pay via PayPal by sending money to noahsarkdestin@gmail.com or mail a $100 check to 250 Indian Bayou Trail, Destin, FL 32541 Make sure to write your child’s name and ‘registration fee’ in the Memo.
You will need to download our school handbook and a copy of the Child Care Facility brochure before filling out this form.

Student Information
Student's name*
First Middle Last
Nickname (if applicable)
Date of Birth
Sex*
Date of Enrollment*
Child's Physical Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Family Information
Child lives with:*
Mother's Name*
First Last
Mother's Email Address*
Mother's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mother's Phone*
Mother's Employer
Mother's Employer's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mother's Work Phone/Cell Phone*
Father's Name*
First Last
Father's Email Address*
Father's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Leave blank if this is the same as the Mother's.
Father's Phone
Father's Employer
Father's Employer's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Father's Work Phone/Cell Phone*
Custody:*
- Mother
- Father
- Both
- Other
If you chose "Other," Please Describe
Medical Information
I hereby grant permission for the staff of this facility to contact the following medical personnel to obtain emergency medical care if warranted.
Doctor / Pediatrician*
Doctor's Office Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Doctor's Phone*
Doctor #2 (if applicable)
Doctor's Office Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Doctor's Phone
Dentist
Dentist Office Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Dentist's Phone
Hospital Preference*
Please list allergies, special medical or dietary needs, or other areas of concern:*

Write "None" if there are none.
Contacts
Child will be released only to the custodial parent or legal guardian and the persons listed below. The following people will also be contacted and are authorized to remove the child from the facility in case of illness, accident or emergency, if for some reason, the custodial parent or legal guardian cannot be reached:
Name #1*
First Last
Phone*
Name #2
First Last
Name #3
First Last
Phone
Name #4
First Last
Phone
Helpful information about your child:
I give my permission:
- To have my child photographed at Noah's Ark preschool to be used for teaching purposes, displays in the school building and end of the year slideshow.
- To have my child photographed at Noah's Ark preschool to be used on the Immanuel Anglican church web page and Noah's Ark web site
- To have my child photographed at Noah's Ark preschool to be used on the Noah's Ark Preschool Facebook page
- To allow my child to participate in the developmental assessment process used in accordance with the Beyond Centers and Circle Time Curriculum. I know and understand these results will only be shared with the director, parents of the child and the child's teacher
- To have my child participate in any of the field trips sponsored by Noah's Ark Preschool with the understanding that I will be given all needed information about each trip 10 days in advance of the field trip date
- For my child to enjoy the menu in special food events such as classroom cooking, events where foods are brought for birthday celebrations, seasonal parties, the annual Fall Festival, the annual Thanksgiving Feast and ice cream truck days. I will provide the school with any allergy of health related issues to foods that my child may have.
Application Checklist*
- I acknowledge that Noah's Ark has made me aware of the school having animals on their property. One saltwater fish tank, one freshwater fish tank and a chicken coop outside the playground area.
- I will submit a current physical within 30 days of enrollment. Section 65C-22.006(2), F.A.C., requires a current physical examination (Form 3040) and immunization record (Form 680 or 681) within 30 days of enrollment.
- I have downloaded and read the Child Care Facility Brochure (located at the top of this page): Section 402.3125(5), F.S., requires that parents receive a copy of the Child Care Facility Brochure, "Know Your Child Care Facility” (CF/PI 175-24), or Section 65C-20.11(2)(c)(1), F.A.C., requires that parent(s) receive a copy of the family day care home brochure, “Selecting A Family Day Care Home Provider” (CF/PI 175-28).
- I have downloaded and read the discipline policy in the Handbook (see top of the page for this download)Section 65C-22.006(3)(c)2., F.A.C., requires that parents are notified in writing of the disciplinary practices used by the child care facility, or Section 65C-20.010(6)(c), F.A.C., requires that a written a copy of the family day care provider’s discipline policy be available for review by the parent(s).
- I have read the school handbook and am informed on the illness policy, the appropriate school clothing, etc. You can find the link to download the handbook at the top of this page.
- I have paid the $100 registration fee via PayPal to: noahsarkdestin@gmail.com or I have mailed my $100 check to 250 Bayou Trail, Destin, FL 32541
Digital Signature
Typing your name in the field below and submitting this form, you are indicating that you have received the above items and that the information on this enrollment form is complete and accurate.
Name*
First Last
Email for registration confirmation*

Student Information

Family Information

Medical Information

Contacts

Digital Signature