First Southern Baptist Church Bryant, ArkansasBryant, AR

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Child

First Name

Last Name

Date of birth

Gender

Preferred Name (Goes by)

Please list Names and Ages of all Siblings

Parents (Legal Guardian)

Mother:

First Name

Last Name

Phone Number

Address

Apartment, suite, etc.

City

State

Postal / Zip Code

Marital Status

Mother's Employer + Weekly Hours + Work Number

Are you on Facebook?

Yes

Your Facebook Name or URL

Father:

First Name

Last Name

Phone Number

Address

Apartment, suite, etc.

City

State

Postal / Zip Code

Marital Status

Father's Employer + Weekly Hours + Work Number

Emergency Contact

Other than Parents

First Name

Last Name

Phone Number

Authorized Pick-up Person

Other than Parents

First Name

Last Name

Phone Number

Church/ Religious Affiliation

Primary Religion in your home?

Where do you actively attend church?

Any relgious or cultural beliefs we should be mindful of?

Medical Information

Primary Doctor + Address + Phone

Preferred Hospital + Address

Please check any of the following that affect your child:

Seizures

Frequent Colds

Nose Bleeds

Sun Sensitivity

Fainting Spells

None of the Above

Is your child being monitored by a doctor for any medical condition?

Yes

Please explain these medical conditions

Is your child taking any medications?

Yes

Please list these medications

Getting to Know Your Child

Is your child potty trained?

Yes

Where are you in the process?

Does your child have any physical challenges?

Yes

Please explain these challenges

Does your child have any emotional challenges?

Yes

Please explain these emotional challenges

Does your child have any dietary needs or food allergies?

Yes

Please explain these needs or allergies

My child can NOT eat:

My child CAN eat:

Any other non-food related allergies?

Yes

Please explain these allergies

What are some of your child's fears and dislikes?

What are some of your child's favorite toys?

What are some of your child's favorite games?

What are some of your child's favorite foods?

What is the best way to show love to your child?

What is the best way to discipline your child?

Are there any special child raising practices you use within your home that we should be mindful of?

Yes

Please explain these practices.

What other information will be useful for us regarding how we care and educate your child?

Anything else you'd like to share that we did not ask?

Acknowledgment & Signature

By submitting this form I hereby give my consent to the Director of First Southern Baptist Church Academy or his/her duly appointed representative, for my child to receive medical or surgical aid as may be deemed necessary and expedient by duly licensed or recognized physician or surgeon in case of an emergency when parents cannot be reached. Consent is also given for the Director or his/her duly appointed representative, to transport, my child for emergency medical treatment or evacuation to a safe place in the absence of a parent.

Yes

My child may be subject to interviews by licensing staff, child maltreatment investigators, and/or law enforcement officials for the purposes of determining licensing compliance or investigative purposes.

Yes

Each teacher/ classroom at FSBC Academy has a private Facebook page. These are used to give reminders of upcoming events and to keep families plugged in to what the children are doing on a day-to-day basis. We are asking permission to post photographs of your child to this page. We will not share names or other personal information about the children. These pages are restricted to parents, the above emergency and authorized pick-up persons.

FSBC Academy has permission to post photos and/or videos of my child on these private Facebook pages.

Yes

I have received information of Kindergarten Readiness Skills Calendar for my child (only for children ages 3-4 years) as found on our website "Getting Ready for Kindergarten."

Yes

I have received information on the prevention of Shaken Baby Syndrome in accordance with Carter’s Law (only for parents of infants) as found on our website "Shaken Baby Syndrome Brochure."

Yes

I have received a copy of our discipline policy as found on page 3 of our Parent Handbook. I understand no physical punishment will be administered at our facility.

Yes

I acknowledge that I have access to and have read the following:

Program Handbook

Tuition Fee & Schedule

Signature (please type your name below)

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Service Times

Sunday Morning LifeGroups
9:00am
Sunday Morning Worship Service
10:30am

Contact Info

(501) 847-3014
604 S Reynolds Rd
Bryant, AR 72022

Child

Parents (Legal Guardian)

Emergency Contact

Authorized Pick-up Person

Church/ Religious Affiliation

Medical Information

Getting to Know Your Child

Acknowledgment & Signature

Our Values

Service Times

Contact Info

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