Pod Enrollment Form Pod Enrollment (To be completed upon acceptance) Welcome — let's get to know your child. Thank you for taking the time to fill this out. This form helps me get to know your child before they arrive, and gives me what I need to keep them safe, comfortable, and well-supported once they do. Some of these questions are practical and some are personal. Please share what feels right to share, and know that we can always follow up in conversation. Anything you tell me here stays between us and any staff who genuinely need to know. About Your Child Legal name* Preferred name or nickname Date of birth* Grade level* Select… 4th 5th 6th 7th 8th Other / multi-age Pronouns Current or previous school Public, private, homeschool, or another pod — whatever applies. Parents & Guardians Please list each parent or guardian with whom we may communicate about your child. Guardian 1 Full name* Relationship to child* Phone* Email* Best way and time to reach you Guardian 2 (if applicable) Full name Relationship to child Phone Email Best way and time to reach you I ask this one because I'd rather know than not. Anything shared stays confidential and only informs how I keep your child safe. Custody arrangements or legal orders we should know about Restraining orders, custody schedules, or any limits on who may have contact with or pick up your child. Emergency Contacts & Pickup These are people other than the guardians above. List at least two we can reach if you can't be reached, and tell us who is authorized to pick up your child. Emergency Contact 1 Name* Relationship* Phone* Authorized to pick up your child? Yes No Emergency Contact 2 Name* Relationship* Phone* Authorized to pick up your child? Yes No Anyone else authorized to pick up your child Name and relationship. Only people on this list (plus the guardians and emergency contacts above) will be permitted to collect your child. Anyone explicitly NOT authorized for pickup or contact If applicable. This stays confidential. Medical & Health The more I know here, the better I can support your child. If something doesn't apply, leave it blank. Pediatrician name Pediatrician phone Health insurance provider Policy number Preferred hospital in case of emergency Allergies Please list all known allergies — food, environmental, medication, insect stings. If your child has no known allergies, write "none." Food allergies Include severity, typical reaction, and what to do. Example: Peanuts — anaphylaxis. EpiPen, then 911. Environmental allergies Pollen, mold, animals, latex, etc. Note severity and treatment. Medication allergies Insect sting allergies EpiPen on file? Yes No If yes — where stored & expiration Asthma inhaler or other rescue meds? Yes No If yes — details & storage Current daily medications Include name, dose, time of day. Note any administered during pod hours. Chronic conditions or ongoing medical concerns Asthma, diabetes, seizure disorder, etc. Dietary restrictions Medical, religious, or family preference. Note anything we need to keep away from your child. Permission to administer OTC medication if needed (Tylenol, Benadryl, etc.) with a phone call to a guardian first Yes No Permission for emergency medical treatment if a guardian cannot be reached Yes No Learning & Support Wherever your child is academically and however they learn best, I want to meet them there. Reading & academic level Select… At grade level across the board Above grade level Below grade level Mixed by subject Not sure Diagnosed learning differences, ADHD, autism, anxiety — anything you'd like me to know What does your child love? What are they good at? What helps your child when they're frustrated, shut down, or overwhelmed? Specific is better than general. A walk, a quiet corner, a check-in — whatever works. Social & Developmental Is there anything about your child's social history at previous schools or programs I should know? Friendships, kids to keep separated, history of being bullied or doing the bullying. Optional, and stays between us. Anything about your child's physical or developmental stage that would help me support them? Privacy needs, supplies they may need access to, anything else. Brief is fine — share what you want to share. Permissions Photo or video for internal program use (records, internal communications) Yes No Photo or video for external sharing (website, social media, marketing) Yes No Field trips and off-site activities Yes No Personal device / phone policy acknowledgment Phones and personal devices are collected at the start of each session and returned at dismissal. Communication during pod hours goes through the instructor. I have read and agree to the personal device policy on behalf of my child. Tell me about your child. This is the most important question on the form. Take your time. Share whatever you'd want me to know if we were having coffee instead of filling out paperwork. What do you want me to know about your child as a person? What are you hoping they get out of this program? Your Acknowledgment I confirm that the information above is accurate to the best of my knowledge, and I will notify the pod instructor of any meaningful changes.* Parent / guardian signature (typed name)* Date* Thank you for trusting me with your child. I'm rooting for them already, and I'll do my best to be the kind of instructor your family deserves. Best,Kelli Clear form Submit enrollment
