Child's Name: *
Please list your child's first and last name
Phone number *
Phone type Mobile Home Work Other
Gender *
Select… Male Female
Potty trained? *
Select… Yes No Working on it
Does your child require an epinephrine autoinjector? *
Select… Yes No
Does your child require an inhaler? *
Select… Yes No
Any other medical information?
Please share with us any other medical information we need to know and also any other information that can help us meet your child's needs while under our care.
Parents/Guardians information: *
Please list parents/guardians first name, last name, best contact number and email address
Emergency contact: *
Should we not be able to reach parents/guardians please list the name, number and relationship to child of any emergency contacts.
Alternate pick-up: *
Please list the name, number and relationship to child of anyone you authorize to pickup your child.
Medical Release: *
I grant Hixson Presbyterian Church, its representatives and employees permission to seek medical attention for my child if necessary while participating in any event sponsored by the church. I understand that necessary precautions will be taken for my child's safety. I will not hold the church, staff, or those supervising liable.
Select… Yes No
Photo/Video permission: *
I grant Hixson Presbyterian Church, its representatives and employees the right to take photographs of my child and my property while participating in any event sponsored by the church for PROMOTIONAL USE. I authorize HPC, its assigns and transferees to publish the same in print and/or electronically. Examples include promotional brochures, website, social media. Please use the drop down to indicate if you DO or DO NOT give permission for PROMOTIONAL USE.
Select… Yes, I do give my permission No, I do not give my permission
Classroom photo use: *
I grant Hixson Presbyterian Church, its representatives and employees the right to take photographs of my child and my property while participating in any event sponsored by the church for USE IN THE CLASSROOM. Examples include craft projects and bulletin board displays. Please use the drop down to indicate if you DO or DO NOT give permission for CLASSROOM USE of photos.
Select… Yes. I DO give my permission No, I DO NOT give my permission
Covid waiver: *
COVID WAIVER: By registering for an event with Little Seekers Day School at Hixson Presbyterian Church, you acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that you and your family may be exposed to or infected by COVID-19. You also acknowledge that the risk of becoming exposed to or infected by COVID-19 may result from the actions, omissions, or negligence of yourself and/or others, including, but not limited to, LSDS employees, HPC employees, volunteers, and participants and their families. You agree to assume all the foregoing risks, waive liability against the Little Seekers Day School at Hixson Presbyterian Church and any other listed parties, and accept sole responsibility for any illness, injury, disability, or death to you or your family, including all claims that may arise resulting from any of these. By writing my name I understand all of what was written above.
Code of Conduct
At the beginning of each school year, children will be taught the Code of Conduct. Parents will be asked to sign this code to promise to support our efforts in requiring their child to respect and abide by the Code of Conduct. By signing this registration form you are agreeing to the code of conduct. All children will have the Code of Conduct reinforced throughout the year by their teacher in an age-appropriate manner.
Signature/Date *
By writing my name below I affirm that I have read and understood the above permissions.
Submit