Online Payment Form

Guardian 1

Mother

Father

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First And Last Name

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Cell Number

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Email Address

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Employer

Business Number

Home Phone Number

Guardian 2

Mother

Father

Please choose an option

First And Last Name

Please Enter Guardian Name Here

Cell Number

Please Enter Cell Number Here

Email Address

Please Enter Email Address Here

Employer

Business Number

Home Phone Number

Does Your Child Speak French?

Yes

Do Parents Speak French?

Yes

IN CASE OF EMERGENCY, WHO CAN WE CALL IF WE ARE UNABLE TO REACH YOU

Name of Doctor (in case of Emergency)

Telephone of Doctor

PLEASE CHOOSE BELOW A SCHEDULE AND TIME FOR THE ACADEMIC YEAR, SEPTEMBER - JUNE

Day Schedule

5 Days a Week: Monday - Friday

3 Days a Week: Monday, Wednesday, Friday

2 Days a Week: Tuesday, Thursday

Schedule Time

Full Day: 8:00 am - 3:00 pm

Full Day + Enrichment: 8:00 am - 6:00 pm

Enrichment only: 3:00 pm - 6:00 pm

MEDICAL STATEMENTS AND CONSENT

Petits Poussins Carroll Gardens is not permitted to administer any medication, if needed, please do so at home or after school.

I (we) authorize staff and Director of Petits Poussins Carroll Gardens to obtain all necessary Emergency Medical treatment, in case of an emergency.

Do you authorize staff and Director of Petits Poussins Carroll Gardens to administer all necessary First Aid care for your child, if necessary?

Yes

List any allergies your child has, or medical conditions, seizures, asthma, handicap, he/she has

Please Enter Street Address Here

Note: All allergies/medical conditions must be stated on the child's medical form. Additionally, a "Standing Order" from the Pediatrician will be required in order to administer an Epi-Pen, Benadryl, or any Asthma medication. Your child will not be admitted without it.

Does your child have any disability? (E.g. Physical Therapy, Occupational Therapy needs, Speech/Language delays, etc.)

Yes

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If yes, Please Specify

Does your child have speech delay?

Yes

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If yes, Please Specify

NEW YORK DEPARTMENT OF HEALTH REQUIRES THAT ALL CHILDREN ARE VACCINATED FOR SCHOOL ENTRANCE

Do you vaccinate your child?

Yes

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I, hereby, authorize Petits Poussins Carroll Gardens to provide care for my child.

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I declare to the best of my knowledge that all statements made in this application are true.

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First and Last Name (Guardian 1)

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First and Last Name (Guardian 2)

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Amount

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Payment For

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Have you been on a school tour of Petits Poussins Carroll Gardens?

Yes

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Where/how did you hear about our school? (Select one or more)

Another website (e.g., French Morning Media, Mommy Poppins, etc.)

Google Search

Facebook Ad

Word of Mouth

Outside School Posters/Signage

I walked by the school

Other

Does the applicant have any siblings?

Yes

Please select an option

If so, what are the age(s) of the applicant’s siblings?

I consent to the collection and processing of my personal information and, where applicable, health-related information, including any data I submit on behalf of others. This is for the purpose of evaluating or fulfilling my request, in accordance with the Privacy Policy.

Card Number

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Name on Card

Please enter your name.

Expiry Date

Please enter your card expiry date.

Security Code

Please enter your card security code (CVV/CVC).

CHILD'S PERSONAL INFORMATION

IN CASE OF EMERGENCY, WHO CAN WE CALL IF WE ARE UNABLE TO REACH YOU

PLEASE CHOOSE BELOW A SCHEDULE AND TIME FOR THE ACADEMIC YEAR, SEPTEMBER - JUNE

MEDICAL STATEMENTS AND CONSENT

NEW YORK DEPARTMENT OF HEALTH REQUIRES THAT ALL CHILDREN ARE VACCINATED FOR SCHOOL ENTRANCE