Bloom Fine Arts Preschool (Oak Ridge) Registration Form

2025-2026 School Year

Student Information

Full Name *

Name to be called/written at school *

Student's Age *

Student must be 3 or 4 by 8/31/25

Date of birth *

Student must be 3 or 4 by 8/31/25

Gender *

Male

Female

Street Address *

City

State

Country

Postal code

Primary Phone Number *

Previous Preschool/Childcare

Child lives with

Both Parents

Dad

Mom

Other

Name(s) & Age(s) of siblings

Medical or Developmental Issues (allergies, hearing, eyesight, behavior, attention deficit, etc.)

Mother / Guardian Information

Name *

Email *

Address

Cell Phone *

Work Phone

Father / Additional Guardian Information

Name *

Email *

Address

Cell Phone *

Work Phone

Authorizations Releases

Emergency Contact Information: *In the absence of parents, child can be released to:

Child Pick up Authorization: *Other than Parents & Emergency Contacts

Is there a court order preventing anyone from picking up your child? (If a court order exists, Bloom will need to be provided with a copy to keep on file.)

Yes

No

Child's Doctor *

Preferred Hospital *

Medical Insurance Company *

Policy Number *

I (here by) authorize Bullseye Entertainment Inc. dba Destination Arts/Bloom Fine Arts Preschool staff to secure medical attention for my child in case of serious illness or accident. I will assume full cost of said medical treatment and will not hold Bullseye Entertainment Inc. dba Destination Arts/Bloom Fine Arts Preschool financially responsible for these costs. I do (here by) release Bullseye Entertainment Inc. dba Destination Arts/Bloom Fine Arts Preschool, their staff and/or volunteers from any and all claim and liabilities of whatsoever nature, both individually and collectively, that may arise from my child participating in activities at Bullseye Entertainment Inc. dba Destination Arts/Bloom Fine Arts Preschool.

Please sign here *

Clear

I allow Bullseye Entertainment Inc. dba Destination Arts/Bloom Fine Arts Preschool to use my child's name and photographic likeness in all forms and media for advertising, trade or any lawful purpose.

Please sign here *

Clear

Sign Here

I understand that this is a full school year program and that I will be billed Sept-May on the 1st of each month. I understand that admission will be granted on a space available basis. I understand that I must submit the a health statement and immunization form by the first day of school. I understand that I can withdraw at any time, but no refunds will be made for withdrawals or absences.

Please sign here *

Clear

Sign Here

I verify my student is fully potty trained. "Potty trained" is defined as wearing underwear during the day, will ask to go, and can go independently.

Please sign here *

Clear

Printed Name of the above signed

First Name *

Last Name *

Date of Signature *

Preschool Class Options

Children entering our 3 and 4-year-old programs should be potty-trained. All classes meet from 9:00am until 12:00pm.

Please select one or BOTH the 2 and 3 day options if you want to attend 5 Days Per Week *

2 Day Program - Tuesday & Thursday

3 Day Program - Monday, Wednesday & Friday