‌R E G I S T R A T I O N F O R M‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌

PLEASE PRINT CLEARLY IN BLUE OR BLACK INK

GENERAL INFORMATION

FULL TIME PART TIME BEFORE/AFTER CARE DROP IN

CHILD INFORMATION

CHILD'S LEGAL NAME:                                                   DOB:                         

GENDER: M F

PREFERRED NAME:                  

CHILD’S ADDRESS: CITY:

STATE/PROVINCE: ZIP/POSTAL CODE:

PARENT/GUARDIAN 1

RELATIONSHIP TO CHILD:                                                     

FULL NAME:

ADDRESS:                                                                CITY:                                   STATE/PROVINCE:                                   ZIP/POSTAL CODE:                                   HOME PHONE:                                           CELL PHONE:                        

EMAIL:

PARENT/GUARDIAN 2

RELATIONSHIP TO CHILD:                                                     

FULL NAME:

ADDRESS:                                                               CITY:                      

STATE/PROVINCE:                                         ZIP/POSTAL CODE:                       

HOME PHONE:                                            CELL PHONE:                                    EMAIL:

‌PRIMARY EMERGENCY CONTACT‌‌

(OTHER THAN PARENTS OR GUARDIAN)

RELATIONSHIP TO CHILD:                                                     

FULL NAME:                                                                   

ADDRESS:                                                               CITY:

STATE/PROVINCE:                                       ZIP/POSTAL CODE:                       

HOME PHONE:                                                                                 CELL PHONE:                         

WORK PHONE:                         

MAY I TEXT YOU? YES NO

SECONDARY EMERGENCY CONTACT

(OTHER THAN PARENTS OR GUARDIAN)

RELATIONSHIP TO CHILD:                                                     

FULL NAME:                                                                   

ADDRESS:                                                               CITY:

STATE/PROVINCE:                                         ZIP/POSTAL CODE:                         

HOME PHONE:                                                                                     CELL PHONE:                         

WORK PHONE:                                           MAY I TEXT YOU? YES NO

AUTHORIZED PICK- UP LIST:

IF YOU PLAN ON HAVING SOMEONE ELSE DROP OFF/PICK UP YOUR CHILD, PLEASE FILL OUT THE FOLLOWING:

FULL NAME:                                                                   

RELATION TO CHILD: PHONE: NOTES:

‌MEDICAL INFORMATION‌‌‌‌‌‌‌‌‌‌

CHILD’S PHYSICIAN:                                                           

PHYSICIAN'S PHONE:                                                        

PLEASE LIST ANY MEDICATIONS:                                            

ARE YOUR CHILD'S IMMUNIZATIONS UP TO DATE?

YES NO

DOES YOUR CHILD HAVE ANY MEDICAL CONDITIONS WE SHOULD BE AWARE OF?

YES NO

IF YES, PLEASE DESCRIBE:

DOES YOUR CHILD HAVE ANY ALLERGIES TO MEDICINE / FOOD WE SHOULD BE AWARE OF?

YES NO

IF YES, PLEASE DESCRIBE:

DOES YOUR CHILD HAVE ANY OTHER ALLERGIES WE SHOULD BE AWARE OF?

YES NO

IF YES, PLEASE DESCRIBE:

DO YOU HAVE ANY CONCERNS ABOUT YOUR CHILD'S DEVELOPMENT?

YES NO

IF YES, PLEASE DESCRIBE:

ADDITIONAL NOTES:                                                          

‌CONSENT INFORMATION‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌

TRANSPORTATION: I GIVE CONSENT FOR MY CHILD TO BE TRANSPORTED AND SUPERVISED BY THE OPERATIONS EMPLOYEES:

FOR EMERGENCY CARE FIELD TRIPS TO AND FROM SCHOOL

SCHOOL AGE CHILDREN: WHAT SCHOOL DOES YOUR CHILD ATTEND?

FIELD TRIPS: I GIVE CONSENT FOR MY CHILD TO PARTICIPATE IN FIELD TRIPS YES NO

WATER ACTIVITIES: I GIVE CONSENT FOR MY CHILD TO PARTICIPATE IN THE FOLLOWING WATER ACTIVITIES:

WATER TABLE PLAY SPRINKLER PLAY SPLASH PADS

SUNSCREEN/INSECT REPELLENT: IF YOU WOULD LIKE THE DAYCARE TO APPLY SUNSCREEN/INSECT REPELLENT, PLEASE PROVIDE US WITH AN UNEXPIRED BOTTLE OF BOTH. PLEASE MAKE SURE YOUR CHILDS NAME IS CLEARLY MARKED ON BOTH BOTTLES.

I GIVE CONSENT FOR THE DAYCARE TO APPLY: SUNSCREEN INSECT REPELLENT

PICTURES/VIDEOS: I GIVE CONSENT FOR THE DAYCARE TO USE MY CHILD’S PICTURE/VIDEO ON THEIR SOCIAL MEDIA AND WEBSITE YES NO

PARENT SIGNATURE:

CENTER DESIGNEE SIGNATURE: