The
Holiday House
Heavenly Hive Homeschool
Forms and Contracts
Please contact Connie Conkright at 859-223-8414 for an appointment to discuss
Heavenly Hive Homeschool opportunities.
Initial enrollment forms can be printed as provided below, sent via email or provided during the interview process.
For more information about Policies and Fees, please refer to the Heavenly Hive Handbook.
THE HEAVENLY HIVE HANDBOOK
CLICK HERE!
The Heavenly Hive Christian Home School
Emergency Information
Name of Child:___________________________________________________________
Birth Date: _____/______/_______ Current Age________ Sex: M__ F__
Health Insurance Information:
Health Carrier: __________________________________________________________
Primary Insured Name:_____________________________________________________
Insurance ID#___________________________________________________________
Child’s Primary Care Physician:______________________________________________
Address:_______________________________________Phone:___________________
Mother’s Preferred Emergency Contact Numbers:
1) ________________________________ 2) ________________________________
Father’s Preferred Emergency Contact Numbers:
1) ________________________________ 2) ________________________________
Other Authorized Person(s) to contact in case of emergency:
1. Name:________________________________________________________________
Relationship to child:____________________________________________________
Home Phone:______________________ Work /Cell Phone:___________________
2. Name:________________________________________________________________
Relationship to child:____________________________________________________
Home Phone:______________________ Work /Cell Phone:___________________
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Student’s Health History
Are your Child’s immunizations up to date? Yes ( ) No ( )
If no, please explain:________________________________________________
_________________________________________________________________
It is required that you submit a current immunization certificate for your child’s records within 30 days of enrollment date.
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Does child have any known health problems? Yes ( ) No ( )
(If yes attach documentation)
Check (√) any of the following illnesses the child has had:
□Asthma □Earaches □Mumps □Whooping Cough □Bronchitis
□Eczema □Pneumonia □Polio □Chicken Pox □Frequent Colds
□Croup □Convulsions □Measles □Influenza □Rheumatic Fever
□Diphtheria □Tonsillitis □Tonsillitis □Other:____________________________
Please list any injuries child has had:________________________________________________________________
____________________________________________________________________
Does you child have any know allergies? Yes ( ) No ( ) If yes, what are they and what are your child’s reactions:____________________________________________________________
____________________________________________________________________
Does your child take any medication on a regular basis? Yes ( ) No ( ) If yes please list the name of the medication(s) and the medical condition for which it is taken:
____________________________________________________________________
Do you have any concerns about your child’s development? Yes ( ) No ( )
If yes please comment: ____________________________________________________________________
____________________________________________________________________
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The request for information concerning your child’s dental, vision and hearing screenings is done to predetermine potential speech and language development problems. We perform a simple sight and hearing evaluation. However, if your child has had a professional assessment, that information will prove beneficial.
Has your child ever had a dental exam? Dentist’s Name/ Date of visit/ Results
____________________________________________________________________
Has your child ever had an eye exam? Doctor’s Name/ Date of visit/ Results
Has your child ever had a hearing exam? Screener’s Name/ Date of screening/ Results
____________________________________________________________________
Please comment on any other medical information/ or special need the child care provider should be aware of: ____________________________________________________________________
What are the arrangements for alternate child care if the child is too ill to attend or become ill while the parents are working and they cannot leave their job?
____________________________________________________________________
I authorize the child care provider/staff to obtain the following services for this child if necessary: Public Health Nurse, Physician and or Ambulance in the event of an emergency.
(Ambulance fees and/or health care costs are the responsibility of the parent/guardian)
__________________________ ____________________________________
(Date) (Signature of parent/guardian)
_________________________________________
(Signature of parent/guardian)
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This document gives the individuals listed below, permission to pick up my child from the Heavenly Hive, without further written consent.
I understand that release of my child will be approved, when timely notification has been given, that someone other than myself will be collecting my child; at a specific time.
I understand that proper identification will be required when arriving and that the party will not be permitted past the entry area.
In the event that the person picking up my child is not on the list, I will provide my prearranged emergency code to insure that the party picking up my child has been given permission to do so.
I understand that the Heavenly Hive will not release a child to any person that does not have a proper child restraint seat in their vehicle.
I will provide a proper Driver’s License number to insure that the person picking up my child is a licensed driver and for verification of ID if needed.
Authorized Person Relationship Driver’s Lic. #
______________________ _________________ ______________
______________________ _________________ ______________
______________________ _________________ ______________
______________________ _________________ ______________
______________________ _________________ ______________
__________________________ ________________________________________
(Date) (Signature of parent/guardian)
________________________________________
(Signature of parent/guardian)
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