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Northwest Missouri State University


Enrollment/Health Inventory Registration (Returning Student)

* indicates required fields

Child Information
* First Name
* Last Name
* Gender Female     Male
* Birthday (format: MM/DD/YYYY)
* Address
* Phone
1. Parent/Guardian 2. Parent/Guardian
* Name: Name:
* Address: Address:
Employer: Employer:
Hours: Hours:
Email: Email:
Work Phone: Work Phone:
Home Phone: Home Phone:
Cell Phone: Cell Phone:
Emergency Contact(s)

Relative or friend if parent/guardian cannot be reached to obtain permission for care and/or to disclose information regarding the child.

Name Relationship Phone
* 1.
* 2.
* 3.
Medical Contact(s)
Name Address Phone
* Dentist
* Doctor
* Hospital
Health History/Medication
Yes No List/Explain
* Allergies
* Medication
* Asthma
* Medical Conditions
* Eye Glasses

Other comments on child's development:

* YES/NO Tylenol

We give permission to Horace Mann Personnel to give child acetaminophen (Tylenol) for minor discomfort.
Yes     No

Authorization for Medical Treatment

Authorization is given to Horace Mann personnel to consent to medical treatment for our child (named above), if we, the parents/guardians or emergency contacts are not available at the time of an injury or illness. I authorize emergency treatment for my child if, at the time of injury or illness in our absence, emergency treatment is recommended by our private physician, a consulting physician of his/her choice, or attending emergency physician. We, the parents/guardians, consent to treatment or hospitalization rendered by reason on this authorization. We also understand that any expenses associated with the medical services including ambulance and emergency room costs will be the responsibility of the parents/guardian.

Additional Permissions

* YES/NO Photographs/Videos

We grant permission for our child to be photographed or video taped in an educational context for use in public relations efforts such as newspaper coverage, for use in conference presentations, or for educational review by the school.
Yes     No

* YES/NO Web Sites

We give permission for our child's photograph or work to be posted on the Horace Mann website or an individual teacher's website in an edcuational context.
Yes     No

* YES/NO Directory Information

We grant permission for directory information to be provided to third party individuals.
Yes     No

Billing

We understand that billing will be completed through the university cashiering office and will be approximately one month later than the service provided. Tuition will be charged on a monthly basis. You can choose to be billed beginning on July 1, 2012 in either 10 monthly payments or 12 monthly payments. If you default in your payments,(tuition or lunch) your child may not be permitted to attend Horace Mann or the Leet Center for Children and Families until the bill is paid in full. For any questions about the billing, call 562-1233.

University Participation

We understand that our child’s attendance at Horace Mann includes participation in activities developed and presented by university practicum students and professors. We understand that this may involve one-on-one interaction with our child. We also understand that any testing, screening, or assessment will be conducted under supervision of the classroom teacher.

Arrival and Departure

We understand the hours of the program (7:50 a.m. – 3:00 p.m.) and agree to arrive no earlier then 7:30 and if not picked up by 3:15 the student will be sent to Bearcat Club Afterschool Program at the parents’ expense.

Person(s) Authorized (other than parents) to take child from the school

Child will not be released to anyone not listed.

Name Relationship Phone
* 1.
* 2.
* 3.
* 4.

* Legal Signature of Parent/Guardian: