Pre-K Registration Form August 2025

GA Lottery Pre-K Registration Form
SCHOOL/SITE NAME*
CHILD INFORMATION
Your child's name : {firstname} {lastname}
firstname
lastname
username
CHILD’S MIDDLE NAME
NAME SUFFIX: (i.e. Jr, Sr, II,III)
Child's Nickname ( if any )
CHILD’S SOCIAL SECURITY#*
CHILD'S D.O.B. *

MonthDayYear
Date
CHILD'S AGE
Cut Off Calculator Date

MonthDayYear
Date
Child's Age on September 1, 2025
Calculation
Aww Snap! Your child must be 4 on or before September 1 to register for ABC's Georgia Lottery Pre-K Program. You will not be able to continue this form.

Today's Date

MonthDayYear
Date
SEX

MaleFemale
Address*

HOME ADDRESS (Do not enter PO Box Info)

Street Address Line 2

CityState / Province

Postal / Zip Code
CITY*
ZIP*
COUNTY
HOME PHONE: ( )
Is the Student transferring from another Pre-K?*

YesNo
If Yes, please provide the Previous School Name
Last Date in Attendance

MonthDayYear
Date

PARENT/GUARDIAN INFORMATION
Parent/Guardian #1 - LAST NAME:*
Parent/Guardian #1 - FIRST NAME*
Parent/Guardian #1 - Home Address (If different from child)
Enter Street Above
City
State
Zip
Parent/Guardian #1 - Cell Phone*
Parent/Guardian #1 - Email Address*
example@example.com
Parent/Guardian #1 - Place of Employment *
Parent/Guardian #1 - Work Phone: ( )*
Parent/Guardian #1 Work Address*
Enter street
City*
State*
Zip*
Parent/Guardian #2:
Parent/Guardian #2 - LAST NAME:
Parent/Guardian #2 - FIRST NAME
Parent/Guardian #2 - Home Address (If different from child)
City
State
Zip
Parent/Guardian #2 - Cell Phone: ( )
Parent/Guardian #2 - Email Address
example@example.com
Parent/Guardian #2 - Place of Employment
Parent/Guardian #2 - Work Phone
Parent/Guardian #2 - Address
City
State
Zip

EMERGENCY CONTACT INFORMATION (Persons to contact in the event that either parent/guardian cannot be contacted)

I verify the above information to be correct, and I understand that completion of this form does not guarantee placement in a Pre-K class. If my child is placed in ABC's Georgia's Pre-K Program, I agree that my child will attend the program for the required number of hours and days as outlined by the center where my child is enrolled. I understand that failure to comply with these attendance requirements could result in disenrollment. I understand that I cannot register my child without appropriate age documentation.
Signature*

Clear
DATE*

MonthDayYear
Date

	Name	Relationship	Cell Phone Number	Email
Emergency Contact #1

	Name	Relationship	Cell Phone Number	Email
Additional Emergency Contact

THE CHILD MAY BE RELEASED TO THE PERSON(S) SIGNING THIS AGREEMENT OR TO THE FOLLOWING:

CHILD’S PHYSICIAN OR CLINIC’S NAME (CHILD’S PRIMARY HEALTH SOURCE):*
CHILD'S PHYSICIAN'S PHONE: *
DATE OF LAST FULL HEALTH SCREENING*

MonthDayYear
Date
MY CHILD HAS THE FOLLOWING SPECIAL NEED(S):
None
THE FOLLOWING SPECIAL ACCOMMODATION(S) MAY BE REQUIRED TO MOST EFFECTIVELY MEET MY CHILD’S
None
MY CHILD IS CURRENTLY ON MEDICATION(S) PRESCRIBED FOR LONG-TERM CONTINUOUS USE AND/OR HAS THE FOLLOWING PRE-EXISTING ALLERGIES, ILLNESS, OR HEALTH CONCERNS:
None

	NAME	ADDRESS	RELATIONSHIP	CELL PHONE
#1

GENERAL RELEASE
I verify the above information to be correct and true. I hereby grant permission for the information provided in the preceding Registration Form to be distributed to Pre-K providers, the Department of Early Care and Learning (DECAL), and certain agencies or those entities contracted by Pre-K providers or DECAL which shall include, but not be limited to, the Georgia Department of Education, and colleges/universities.
Signature*

Clear
DATE*

MonthDayYear
Date
PHOTOGRAPH/VIDEOTAPE RELEASE
I hereby grant permission for the Pre-K provider specified below, the Georgia Department of Early Care and Learning (DECAL) and certain agencies or entities contracted by the Pre-K provider or DECAL which shall include, but not be limited to, the Georgia Department of Education, and colleges/universities, to record the participation and appearance of my child, {firstname} {lastname} by photograph and/or videotape in connection with daily Pre-K activities for the purposes of news releases, reporting, and assessing the progress of children and the program. DECAL and its contractors are authorized to exhibit or distribute such photograph(s) and/or videotape in whole or in part without restrictions or limitations for any educational or promotional purpose that DECAL deems appropriate. Such photograph(s) and/or videotape may, for example, appear in printed or visual materials for DECAL and/or on DECAL’s web site.

The undersigned hereby jointly and severally releases, acquits, forgives, and discharges the Pre-K provider, DECAL, and other entities contracted by the Pre-K provider or DECAL, from any actions, agreements, claims, controversies, demands, judgments, liabilities, proceedings, and suits, whether arising in equity or in law regarding such participation and appearance by said child.

This release shall remain binding upon all successors in interest and personal representatives of the parties, to the extent permitted by law.

PRE-K PROVIDER NAME/ADDRESS: ABC ELA, P.O. Box 28524, Atlanta, GA 30358
Signature*

Clear
DATE*

MonthDayYear
Date

Parental Agreements with Child Care Facility
Name of Child
My child will participate in the following meal plan; Breakfast, Lunch and afternoon snack.

Before any medication is dispensed to my child, I will provide a written authorization, which includes: Date, Name of Child, Name of Medication, Prescription Number (if any), Dosages, and Date and Time of Day to be given to child. Medicine will be in the original container with my child’s name marked on it.

My child will not be allowed to enter or leave the facility without being escorted by the parent(s), person(s) authorized by parent(s), or facility personnel.

I acknowledge it is my responsibility to keep my child’s records current to reflect any significant changes as they occur, e.g., telephone numbers, work location, emergency contacts, child’s physician, child’s health status, infant feeding plans, and immunization records, etc.

The facility agrees to keep me informed of any incidents, including illnesses, injuries, adverse reactions to medications, etc., which include my child.

ABC Early Learning Academy agrees to obtain written authorization from me before my child participates in routine transportation, field trips, special activities away from the facility, and water-related activities occurring in water that is more than two (2) feet deep.

I authorize the child care facility to obtain emergency medical care for my child when I’m not available.

I have received a copy and agree to abide by the policies and procedures for the above-named facility.
Signature*

Clear
Date*

MonthDayYear
Date

	BOTH PARENTS	MOTHER	FATHER	OTHER
CHILD'S LIVING ARRANGEMENTS:
CHILD'S LEGAL GUARDIAN

GA Lottery Pre-K Registration Form

CHILD INFORMATION

Your child's name : {firstname} {lastname}

PARENT/GUARDIAN INFORMATION

GENERAL RELEASE

PHOTOGRAPH/VIDEOTAPE RELEASE

Parental Agreements with Child Care Facility

CHILD INFORMATION:

PARENT/GUARDIAN INFORMATION: