Student Enrollment – LlifeChange Learning Center

Child Information

Child's First Name

Child's Last Name

Child's Birthdate

Street Address

Child's Gender at Birth

City

State

Zip Code

Parent Information

Parent/Guardian #1 - First Name

Parent/Guardian #1 - Last Name

#1 Cell Phone

#1 Email

#1 Employer & Position at Work

#1 Work Phone

Parent/Guardian #2 - First Name

Parent/Guardian #2 - Last Name

#2 Phone

#2 Email

#2 Employer & Position at Work

#2 Work Phone

Special Situation

Please Give Details on the Situation

Emergency Information

Name of Emergency Contact #1 (Must Live in 45 Mile Radius of Sioux Falls)

Relationship to Child

Emergency Contact Phone #1

Name of Emergency Contact #2 (Must Live in 45 Mile Radius of Sioux Falls)

Relationship to Child

Emergency Contact Phone #2

Preferred Physician

Physician Phone

Hospital Preference

Preferred Dentist

Dentist Phone

Medical History

All Allergies

File Upload

Maximum file size: 10MB

Medical Conditions/Diseases/Chronic Illnesses

Prescribed Medications

Has Your Child Ever Been Hospitalized? (Please Explain)

Has Your Child Ever Had Trouble With His/Her Hearing or Vision? (Please Explain)

Has Your Child Ever Had Any Serious Accidents or Poisoning? (Please Explain)

Does Your Child Require Any Special Accommodations? (Please Explain)

Student *Last* Name

SDIS Record Permission

I give permission to LifeChange Learning Center Center at 6300 W 41st Street, Sioux Falls, SD 57106, access to the above child's immunization record in the South Dakota Immunization Information System.

To ensure the South Dakota Department of Health is aligning with the Health Insurance Portability and Accountability Act (HIPAA) Omnibus Rule, a School Official must obtain parent, guardian or legal representative agreement before accessing a student's immunization record in the South Dakota Immunization Information System (SDIS). No student record shall be accessed by a School Representative in the SDIS without parent, guardian or legal representative agreement.

Signature

Clear

Today's Date

Classroom Info and Requests

Infant Program (4 Weeks - 12 Months)

Please mark the desired classroom placement for your child below. Official classroom placements are made according to availability and are not always guaranteed. Half Day Class Times AM: 8:30-11:14 PM: 12:30-3:15

Toddle Program (12 Months to 3 years)

Please mark the desired classroom placement for your child below. Official classroom placements are made according to availability and are not always guaranteed. Half Day Class Times AM: 8:30-11:14 PM: 12:30-3:15

Pre-School Program (3 Years - 5 Years)

*All children must be completely potty trained to attend preschool class offerings* Half Day Class Times AM: 8:30-11:14 PM: 12:30-3:15

Pre-K

Please mark the desired classroom placement for your child below. Official classroom placements are made according to availability and are not always guaranteed. Half Day Class Times AM: 8:30-11:14 PM: 12:30-3:15

Kinder Ready

Full-Time is the only option for Kinder Ready

School Age Program (5 Years - 12 Years)

*A registration form for Summer Blast and each new School Year must be completed when registration opens in order to reserve a spot. We do not automatically enroll students in these programs from year-to-year*

Please Indicate Which Elementary School Your Child Attends

We offer bus transportation to and from school during the school year. This information helps us know where we will be taking and picking up your child.

Consent

Please read each statement carefully and place a check-mark in the box when agree to the LCC policy listed.

Transportation