Genesis Academy Pre-K Program

Registration Form
120 South St. Newburgh, NY 12550
Tel 845-562-0081 · Fax 845-562-0031
www.genesis-academy.org

Genesis Academy is a high quality after school program that has made a conscious decision to invest in
our youth by addressing and fulfilling the academic, social, emotional, and spiritual needs of each student.

Child’s Information:
Child’s Name (First): ___________________________ (Last): _______________________________
Child’s Age: __________ Date of Birth: _______/_______/_______ Gender M _______ F _______
Address: ____________________________________________ Apt: ___________ Zip: ____________
Enrollment Date: ________/________/_________ Home Phone number: _________________________
Name of School District: _______________________________________________________________
Language(s) other than English spoken at home: ____________________________________________

Parent’s Information:
Mother/Guardian: ______________________________ Father/Guardian: _______________________
DOB:_________________________________________ DOB:________________________________
Work Phone #: ________________________________ Work Phone #: ________________________
Cell #: _______________________________________ Cell #: _______________________________
Address:_______________________________________ Address:______________________________
Apt:__________________________________________ Apt:_________________________________
Zip:__________________________________________ Zip:_________________________________
Email address: _________________________________ Email address: ________________________

Employer’s Name_______________________________ Employer’s Name______________________

Employment Address____________________________ Employment Address____________________

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Emergency Contact other than parent:
Name: _______________________________________ Relationship:__________________________
Home Phone Number:___________________________ Cell Number: _________________________
Name: _______________________________________ Relationship:__________________________
Home Phone Number:___________________________ Cell: ________________________________
Name: _______________________________________ Relationship:__________________________
Home Phone Number:___________________________ Cell Number: _________________________
Child’s Physician______________________________________________________________________
Telephone Number_____________________________________________________________________

At dismissal, the following people are authorized to pick up my child (Please list an additional 6 people to
pick up your child. A valid photo I.D. must be shown at time of pick-up). All authorized pickups must
be 18 years and older no exceptions.
1. ___________________________________________ 2. ___________________________________
3. ___________________________________________ 4. ___________________________________
5. ___________________________________________ 6. ___________________________________

Medical Information
Daily Medication Name______________________ Dosage________ Time(s) of Day_______________
Allergies (Food, Medicine, Environment)___________________________________________________
Medicine for treatment of allergies________________________________________________________
Any other medical problems or special medical instructions_____________________________________
_____________________________________________________________________________________
Medically prohibited activities____________________________________________________________
Special diets or needs___________________________________________________________________
Child’s Physician______________________________________________________________________
Telephone Number_____________________________________________________________________
In Emergencies requiring immediate medical attention, your child will be taken to the nearest
hospital Emergency Room. Your signature authorizes a responsible person at the center to

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accompany your child and remain with your child at the hospital. I understand that I will be
notified as soon as possible.
____________________________________ __________________________
Signature of Parent/Guardian Date

Photographs/Videotape Recordings Permission Request

During this school term we will be having many fun and exciting learning activities. We would like to
document these activities by photographing and/or filming the students. We need your support and
agreement to allow us to do this. The pictures/filming will be done during classroom activities, field trips,
etc. The pictures may be posted at school, used in our newsletter, slide shows, and school web community
or for school projects, Yearbook, and local newspapers.

I release Genesis Academy, Inc, its officers, employers, agents, and successors from all claims, demands,
actions, causes of actions, suits, damages, and judgments as a result of the use of the above information
about my child in the publications and other activities described above.

Yes, you may photograph/film my child for the purposes stated above.

No, I do not want my child photographed or filmed.

Child’s Name_____________________________________________________________

Parent/Guardian Signature __________________________________

Date ____________________________

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Parent Agreement
I, ________________________________________, am aware that there are no refunds under
Print Parent/Guardian Name
any circumstance. In addition, I am fully aware of and agree to pay a $5.00 late for the first 15
minutes and $1.00 for each additional minute if my child is picked up later than 3:00 pm.
Balances are due by the 1st of each month. Any balance unpaid after the 5th of each month will
accrue a $10 late fee.

___________________________________ ______________________________
Parent/Guardian Signature Date

*An installment plan can be worked out for parents if needed.

=======================================================================================================

I give my child,______________________________ permission to leave the site premises under

Print Child’s Name
adequate supervision by staff for neighborhood walks, trips to the park, or field trips. Advance
notification will be given prior to field trips and permission slips will be sent home and returned with
parent/guardian signature.

I understand and agree that Genesis Academy is not responsible for lost or stolen items children may
bring to school.

__________________________________ ________________________________
Parent/Guardian Signature Date

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Authorization to Release Health and other Information
Name_____________________________________________ Date of Birth______________________

Address______________________________________________________________________________

Telephone____________________________________________________________________________

Information to be released from___________________________________________________________

Address______________________________________________________________________________

I hereby authorize the above entity to release and/or obtain the following information for the purpose of
educational, health, future planning of the above named student.

Current Medications
Educational Evaluations/IEP
Standardized State Test Scores
Formal/Informal Assessments
Other records as specified___________________________________________________________

___________________________________ ______________________________
Signature of Parent/Guardian Date

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Behavior Information

Child’s Name_________________________________________________________________________

Child lives with: Mother Father Both Other (Please specify)

What would you like us to know about your child?____________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

What are your hopes for your child in our Preschool program?___________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

What are your child’s strengths?___________________________________________________________

_____________________________________________________________________________________

In what areas would you like to see your child improve?______________________________________

_____________________________________________________________________________________

What activities does your child typically enjoy?______________________________________________

_____________________________________________________________________________________

How does your child solve problems?______________________________________________________

_____________________________________________________________________________________

What would be a learning goal for your child?________________________________________________

_____________________________________________________________________________________

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We are always looking for volunteers in our program that can offer their time. What would you be able to
contribute to our program? (occupation, hobbies, interests)?_____________________________________

_____________________________________________________________________________________