Operation Name

Director's Name

Child's Full Name

Child's Home Telephone Number

Child's Date of Birth

Date of Admission

Date of Withdrawal

Child's Home Address

Street Address City State ZIP Code

Parent's or Guardian's Name

Address (if different from child's address)

Street Address City State ZIP Code

List telephone numbers below where parents/guardian may be reached while child will be in care:

Mother's Telephone Number

Father's Telephone Number

Guardian's Telephone Number

Give the name, address and phone number of person to call in case of an emergency if parents / guardian cannot be reached:

Name

First Last

Address

Street Address City State ZIP Code

Relationship

I hereby authorize the childcare operation to allow my child to leave the childcare operation ONLY with the following persons. Please list name & telephone number for each. Children will only be released to a parent or a person designated by the parent/guardian after verification of ID.

CHECK ALL THAT APPLY

Transformation:

I hereby

give
do not give

Consent for my child to be transported and supervised by the operation’s employees:

for emergency care
on field trips
to and from home
to and from school

Fields Trip

I hereby

give
do not give

my consent for my child to participate in Field Trips

Parent's Comments

Water Activities

I hereby

give
do not give

My consent for my child to participate in Water Activities:

Sprinkler play
Splashing/wading pools
Swimming pools
Water table play

RECEIPT OF WRITTEN OPERATIONAL POLICIES:

I acknowledge receipt of the facility’s operational policies including those for discipline and guidance.

I UNDERSTAND THAT THE FOLLOWING MEALS WILL BE SERVED TO MY CHILD WHILE IN CARE:

None
Breakfast AM Snack
Lunch
PM Snack
Supper
Evening Snack

MY CHILD IS NORMALLY IN CARE ON THE FOLLOWING DAYS AND TIMES:

Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

AUTHORIZATION FOR EMERGENCY MEDICAL ATTENTION:

In the event I cannot be reached to make arrangements for emergency medical care, I authorize the person in charge to take my child to:

Name of Physician

Phone

Address

Street Address City State ZIP Code

Name of Emergency Medical Care Facility:

Phone

Address

Street Address City State ZIP Code

Signature - Parent or Legal Guardian

I give consent for the facility to secure any and all necessary emergency medical care for my child.

Date

Step 1 of 2 - Page 1

CHECK ALL THAT APPLY

Transformation:

Fields Trip

Water Activities

RECEIPT OF WRITTEN OPERATIONAL POLICIES:

AUTHORIZATION FOR EMERGENCY MEDICAL ATTENTION:

SCHOOL AGE CHILDREN:

IMMUNIZATION RECORD:

ADMISSION REQUIREMENT:

VISION

HEARING

Admission Form

Admission Form

Step 1 of 2 - Page 1

CHECK ALL THAT APPLY

Transformation:

Fields Trip

Water Activities

RECEIPT OF WRITTEN OPERATIONAL POLICIES:

AUTHORIZATION FOR EMERGENCY MEDICAL ATTENTION:

SCHOOL AGE CHILDREN:

IMMUNIZATION RECORD:

ADMISSION REQUIREMENT:

VISION

HEARING