Ross University Day Care School Form

STUDENT'S INFORMATION

First Name: Last Name: Date of Birth: Age:

Gender: Citizenship: Last School Attended:

Expected Start Date:

Language spoken at home: Siblings students lives with:

PARENT'S INFORMATION

Suffix: First Name: Last Name:
Suffix: First Name: Last Name:

Dominica Address:
Cell Phone:               e.g. 7325551234 or +0014325550987
Land Line:                e.g. 7325551234 or +0014325550987

Permanent Address:
Cell Phone:                 e.g. 7325551234 or +0014325550987
Land Line:                   e.g. 7325551234 or +0014325550987

Email (newsletters & other communications are often sent electronically):
Semester the parent is enrolled:

MEDICAL INFORMATION

Does the student have any existing medical or physical condition that we should be aware of?

If yes , please provide a brief explanation.

Does the child has proof of immunization record?

Are there allergies we need to be aware of? If so, please specify

EMERGENCY CONTACT INFORMATION

Emergency Contact Name: Phone Number:
Relationship to child:

Emergency Contact Name: Phone Number:
Relationship to child:

DECLARATION

I declare the information I have provided on this form is complete and accurate.

Signature of parent: Date: 09/23/17

SEMESTER FEE SUMMARY

Please identify the program you wish:

Payment is due at time of registration. Please pay Daycare staff. $50.00 USD late penalty applies after the first of the month. US cheques have a $10.00 processing fee.

FINANCIAL OBLIGATION

I agree to pay the fee of $ . as stated in the Semester Fee Summary above.

Signature of parent: Date: 09/23/17

Media Release Consent

I hereby grant to Ross University Preparatory School (RUPS) and Daycare the right to use my child's name, images, and recordings or the purpose of publicizing the university, the Preparatory School and the Daycare. I consent to the distribution of my child's picture and images by publication, broadcast, and any other means of distribution e.g. Ross email and Ross Website.


Signature of parent: Date: 09/23/17

Please type in the above letters (no spaces):