Registration Form - Kids Harbor (Page 2 of 4) in pdf

Registration Form - Kids Harbor Page 2

Medical Information:

Phone:

Primary Physician:

Dentist:

Phone:

Allergies:

Yes

Possibly

if yes please list them and their severity if exposure occurs:

Special accommodations or limitations:

Please list any regular “maintenance” medications prescribed for your child:

*All medications must be accompanied by a Medication Authorization Form and dropped off

at the front desk. All over the counter medications must also have a doctor’s note in order to

be administered. Medication will only be administered 1 time a day, before lunch.

*Children will not be allowed to remain in the center when displaying signs of illness such as:

fever of 100 degrees or higher, vomiting, diarrhea, undiagnosed rash or other like symptoms.

Children must be fever and symptom free for 24 hours without the use of medication before

returning to the center. Please refer to Parent Handbook for more information.

In the event you cannot be reached please list 3 emergency contacts:

1. Name:

Relationship to child:

Phone:

Alternate Phone:

Address:

2. Name:

Relationship to child:

Phone:

Alternate Phone:

Address:

3. Name:

Relationship to child:

Phone:

Alternate Phone:

Address:

Release for Treatment

In the event of an emergency involving my child and Kids Harbor personnel

cannot reach me, I hereby authorize any needed medical care. I further agree

to be fully responsible for all expenses incurred during the treatment of my child.

Parent Signature:

Date:

Parent Signature:

Date:

*In the case of a medical emergency Kids Harbor will call 911 and children will be transported

to Gwinnett Medical Center for care.

*Kids Harbor does not carry Liability Insurance Coverage sufficient to protect your child in the

event of an injury.

Registration Form - Kids Harbor Page 2

Related Articles

Related forms

Related Categories