Enrollment Form

Child Information

First name

Last name

Birthday

Month

Day

Year

Gender

Male

Female

Other

Parent/Guardians Full Name

Relationship To Child

Contact Infomation

Address

Phone

Emergency Contact Full Name

Emergency Contact Number

Medical Information

Does the child have any medical conditions or allergies? If yes, please specify:

Does the child take any medications? If yes, please list them:

Name of Child's Primary Care Physician:

Physician's Phone Number:

Autism Diagnosis

Date of Autism Diagnosis

Name of Diagnosing Physician or Specialist:

Briefly describe any specific challenges, sensitivities, or behaviors related to autism that we should be aware of:

Educational/Therapy Information:

Is the child currently receiving any special education or therapy services (e.g., speech therapy, occupational therapy, ABA therapy)? If yes, please specify:

Additional Information:

Please share any additional information about your child's interests, strengths, and preferences that will help us provide the best care and support:

Photography Consent:

We occasionally take photos of children during daycare activities for documentation and promotional purposes. Do you grant permission for your child's photo to be used for these purposes?

Yes

Emergency Medical Consent:

In case of a medical emergency, I authorize JVS Ausome Academy staff to seek medical treatment for my child, and I will be responsible for any associated medical expenses.

Parent/Guardian Name

Today's Date

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