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Stillwater Field School

Registration Form

Preschool Program

Parent(s) or Guardian(s) Name(s)

*

Email Address

*

Student's Name

*

Student's Gender

*

A

male

B

female

Student's Birthday

*

Contact Number

*

Do you receive Text Messages at this number?

*

YES I DO!

Street Address

*

City

*

Zip Code

*

Please Select Your Preferred Session

*

A

M/W (350$/month)

B

T/Th (350$/month)

C

M-Th (650$/month)

Please Select Your Preferred Location

*

SFS at Sweet Mercy Farm ( Glenrose Area )

There is an annual $150 registration/supply fee,

per family, due once your learner has been admitted.

This can be paid through Square.

Last Month's Tuition is also due at the time of registration. (Non-refundable).

Note: We occasionally take pictures of the kids in action, we hope to use these to keep parents up to date on the happenings at school through our parent-connection app. We also occasionally post photos to our social media or website.

Do you give Stillwater Field School permission to use photographs of your child?

*

A

YES

B

NO

C

Only for the parent-connection App (no socials)

D

Only for Websites & App

E

Only for Flyers/Advertisements & App

Parent/Guardian Name of Employer

*

What is your Marital Status?

*

A

Married

B

Cohabiting

C

Divorced

D

Separated

E

Widowed

F

Single

Please List the people who have *Permission to pick up your child

*

*Note: Anyone picking up your child must have a picture ID that includes Name, Number & relationship to your child.

Please List the people who DO NOT have *Permission to pick up your child

*

*Note: Please explain the reason or talk with us so we aware of the situation. If the person is a legal parent or guardian, we must have a copy of court ordered restraining order.

List (2) LOCAL Emergency Contacts

*

(other than the parents or guardian. Please include Name, Number & Relationship to your child.)

Regular Medication Taken by Child

Child's Blood Type

*

Medicine Child is Allergic to

Food Allergies

Other Allergies

Any Special Health Conditions

A

YES

B

NO

If YES Please Describe

*

Has your child ever been evaluated for : ADD/ADHD, Autism, Behavior Issues or Depression?

*

A

YES

B

NO

Does your child currently have an IEP?

*

A

YES

B

NO

Does your child have any clinical Hearing, Visual or Speech Conditions?

*

A

YES

B

NO

Stillwater Field School does not discriminate because of race, religion, gender, culture or ability. The information you provide helps us learn more about your child and family to better serve your specific needs.

Religious provisions we should be aware of ( ex. foods not to eat, holidays to celebrate, etc.)

(ex. foods not to eat, holidays to celebrate, etc.)

Specific Cultural Practices we should be aware of?

Does your child have any previous peer group interactions?

*

(ex. daycare, church groups,play groups, sports, etc.)

A

YES

B

NO

If YES , describe how your child interacts with others in these situations

*

(ex. outgoing, shy, energetic, etc.)

Please List any specific strengths, interests, dislikes or fears that can help us get to know your child better.

*

(ex. loves art, is a natural leader, afraid of thunder, etc.)

Please List any specific goals you or your child have while attending Stillwater Field School.

*

(ex. wants to overcome fear of heights, wants child to work on pronunciation, etc.)

Any other information you would like to provide us to help guide your child's experience at Stillwater Field School?

I herby sign that all information I have provided is true and up to date of

Today's Date

*

Parent / Guardian Name

*

Signature

*

Signature

I (the natural parent of legal guardian) hereby give permission (initial below) that my child (fill in below) may be given emergency medical treatment to include First Aid and CPR by a qualified child care provider at Stillwater Field School. I further authorize and consent to medical, surgical and hospital care, treatment and procedures to be performed for my child by a licensed physician, dentist, health care provider, or hospital when deemed necessary or advisable by the physician to safeguard my child's health. I waive my right of informed consent to such treatment. * I give my permission for my child to be transported by ambulance or aid car to an emergency center for treatment.

Child's Name

*

Parent/Guardian Initials

*

*I give my permission for my child to be transported off-site should the center need to be evacuated in the event of an emergency.

Parent/Guardian Initials

*

*I certify ( or declare ) under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct.

Parent/Guardian Initials

*

*if you choose not to give permission, please provide a court signed waiver and alternate emergency plan in case you cannot be reached.

BOTH PARENTS MUST SIGN

*

or Parent with Sole Custody of the child.

Parent 1 Signature

BOTH PARENTS MUST SIGN

*

Parent 2 Signature

Today's Date

*

This authorization shall remain valid until revoked by me, (the parent of guardian ) in writing. Authorizations to this form can only be done by parent(s) who have completed & signed the form.

Parent / Guardian Initials

*

I commit to registering my child for the 2026 / 2027 school year and recognize that my $150 security deposit is non-refundable.

*

Signature

What is your preferred method of payment? Credit Card (3.5% surcharge) OR ACH (1% surcharge)

*

A

ACH

B

Credit Card

If your billing address is different from the one above, please list it here:

How did you find us?

*

A

Flyer

B

Google / Other Search

C

Social Media

D

Friend

E

Other

If you were referred by a friend please let us know who, so we can thank them!

*