Red Daycare Registration Form - 2016-2017 printable pdf download

Red Daycare Registration Form - 2016-2017

RED DAYCARE REGISTRATION FORM 2016-2017

CHILD’S INFORMATION

DATE REGISTERED_________________ DATE FINISHED_________

PHOTO NUMBER_______

CHILD’S NAME_________________________ SEX_____ BIRTHDATE____________

COMPLETE HOME ADDRESS_________________________________________________________________

PHONE_______________ CELL PHONE_____________ EMAIL__________________

CONTACT INFORMATION

LOCAL ADDRESS/ACCOMMODATION ________________________________________________________

MOTHER’S NAME________________________ FATHER’S NAME__________________________

EMERGENCY CONTACT NAME_________________________________ PHONE_____________________

ADDRESS_________________________________________________________________________________

NAME(S) OF PERSON(S) AUTHORIZED TO PICK UP CHILD FROM DAYCARE______________________________

_________________________________________________________________________________________

ANYONE WHO IS NOT AUTHORIZED TO PICK UP CHILD_____________________________________________

MEDICAL INFORMATION

FAMILY DOCTOR_______________________________________________ PHONE___________________

MEDICAL INSURANCE PLAN NAME______________________________ POLICY #_________________

IMMUNIZATIONS YES NO

DOES THIS CHILD HAVE ANY KNOWN MEDICAL PROBLEMS OR DIET

RESTRICTIONS_______________________________________________________________

INSTRUCTIONS TO FOLLOW IN THE EVENT OF AN ALLERGIC

REACTION_____________________________________________________________________

I HEREBY GIVE MY CONSENT FOR THE FOLLOWING:

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A DIGITAL IMAGE TO BE TAKEN AND SAVED OF CHILD IN THE CASE OF AN EMERGENCY

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FOR THE CAREGIVERS TO SEEK EMERGENCY MEDICAL TREATMENT FOR MY CHILD IF NEEDED. I AGREE

THAT ANY COSTS FOR SUCH SERVICES SHALL BE MY RESPONSIBILITY.

PARENT SIGNATURE___________________________DATE____________________

Red Daycare Registration Form - 2016-2017