Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Child's Full Name *FirstLastName of Person Enrolling Child *FirstLastRelationship to Child *ParentGuardianCaretakerRelativeOtherIf 'Other', Please Explain the RelationshipPhone Number of Person Enrolling Child *Can we text this number? *YesNoAddress of Person Enrolling Child *First Emergency Contact Name *FirstLastFirst Emergency Contact Address *Authorized to Pick up Child?YesNoPhone NumberCan we text this phone number?YesNoOther Phone Number / EmailSecond Emergency Contact Name FirstLastSecond Emergency Contact Address Authorized to Pick up Child?YesNoPhone Number Can we text this phone number? YesNoOther Phone Number / Email Third Emergency Contact Name FirstLastThird Emergency Contact Address Authorized to Pick up Child? YesNoPhone Number Can we text this phone number? YesNoOther Phone Number / Email Child's Full Name *FirstLastChild's Date of Birth *Check the boxes below to indicate if your child has any special needs/services: *NoneEarly Intervention/ Special EducationOccupational TherapySpeech/LanguagePhysical TherapyAllergiesOther by enrollment Phone If 'Allergies' or 'Other', Please provide the information here AND discuss with your childcare provider:Child's Primary Care Physician's Name: *FirstLastChild's Primary Care Physician's Group:Preferred Hospital:Child's Dental Care:Parent/Guardian Name *FirstLastAgreement: I consent to emergency medical treatment for my child. *YesNoI consent for my child to take part in neighborhood trips (i,e., library, park and playground) away from the program under proper supervision. *YesNoI understand the program may need additional permissions for situations such as transportation, medication, release of information, and field trips. *YesNoI provided information on my child's special needs to the program to assist in caring for my child. *YesNoI understand the program must give parents, at the time of enrollment of a child, a written policy statement as required by regulation. *YesNoI agree to review and update this information whenever a change occurs and at least once every year. *YesNoPermission & Agreement *I agree and give my permissionSubmit
