Springwell Application | Early Learning Enrollment

Application

Child's First and Last Name

Date of Birth

Month

Day

Year

Gender

Female

Male

Address

Primary Parent/Guardian's Full Name

Relationship to Child

Primary Phone

Secondary Phone

Secondary Parent/Guardian's Full Name

Relationship to Child

Primary Phone

Secondary Phone

Primary Emergency Contact (other than parent/guardian)

Relationship to Child

Phone Number

Allergies or Dietary Restrictions

Medical Conditions

Medications

Pediatrician's Name

Pediatrician's Phone Number

I authorize Spring Well Foundation to seek emergency medical care for my child if necessary.

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Date

Month

Day

Year

Please check the option(s) for which you are enrolling your child

Specify days and times

Special Interest or Strengths

Behavioral and Discipline Strategies Used at Home

Known Fears or Comforts

I give permission for Field Trips

I give permission for photo/video release during school activities.

I give permission for the use of sunscreen/insect repellent if needed.

I have read and agree to abide by Spring Well Foundations' policies, including attendance, illness, and behavior policies. I understand that all information provided is accurate to the best of my knowledge.

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Date

Month

Day

Year