Name Of Child:
Birthdate:
Enrollment Date:
Persons authorized to pick up your child and/or contact in case of emergency if neither parent is available to assume responsibility for the child.
Name of person PROHIBITED from picking up your child:
if a non-custodial parent has been denied access, or granted limited access, to the child by a court order, please submit documentation to this effect for the center to maintain a copy on file, and to comply with the terms of the court order.
I give permission for my child to participate in WALKING TRIPS within the center's neighborhood, using routes that pose no known safety hazards to children, with the understanding that the walk involves no entrance into another facility unless otherwise indicated
I DO NOT give permission for my child to participate in WALKING TRIPS within the center's neighborhood, using routes that pose no known safety hazards to children, with the understanding that the walk involves no entrance into another facility unless otherwise indicated
I give permission for my child to be PHOTOGRAPHED during normal daycare hours, field trips, or activities and understand that photographs may be used in promoting child care services, either in print or on the Internet.
I DO NOT give permission for my child to be PHOTOGRAPHED during normal daycare hours, field trips, or activities and understand that photographs may be used in promoting child care services, either in print or on the Internet.
I (we) attest that all of the information on this application is accurate, and that I (we) have received the following information:
Center Policies and Procedures
Information to Parents Document
Policy on the Expulsion of Children from Enrollment
Policy On The Use Of Technology And Social Media
Policy On The Management Of Illnesses/Communicable Diseases
Policy On The Release Of Children
Policy on the Methods of Parental Notification of Injuries (if applicable)
Other
Child’s Health Care Provider:
Health Care Provider Phone:
Health Care Provider Address:
Name Of Insurance Company/Hmo:
Group:
Identification:
Subscriber’s Name On Insurance Card:
Known Allergies (including medication):
Medication My Child Is Taking:
List Special Conditions, Disabilities, Medical/Physical Restrictions, Medical Information For Emergency Situations:
As the parent/guardian of the above named child, I certify that he/she is in good physical health and may participate in the normal activities of the program and has no conditions or specific needs that require specific accommodations, unless otherwise indicated in the medical information provided above or an attached Universal Health Record or a Care Plan for Children with Special Health Needs.
As the parent(s)/ legal guardian(s) of the above named child, I (we) attest that the information above is correct. I (we) authorize the child care center staff to obtain emergency treatment for my child and understand that I (we) shall be promptly notified.
Submit
