Contact Information - Enrollment Agreement Form

For office use only:

Date received: ______________

Peace Childcare Learning Center

Registration fee paid: ________

Other paperwork received:

o Health History Form

o Immunization Record

o Health Exam Form

Contact Information – Enrollment Agreement

Child’s Full Name: __________________________________________ Birthdate: _____________________

Address: ____________________________________________________________ Phone Number: ______________________

Child’s Physician: ______________________________________ Physician/Medical Facility Phone Number: _______________

Complete Address of medical facility: _________________________________________________________________________

Home Congregation / Affiliation: ________________________________________ Baptism Birthday: ____________________

Parent/Guardian #1

*My child is enrolled at Peace Lutheran School: YES / NO ________

Name: ___________________________________________________________ Relationship to child: _____________________

Address: _________________________________________________________________________________________________

Home Phone: _______________________ Work Phone: _______________________ Cell Phone: _______________________

Email address: ____________________________________________________________________________________________

Employer Name: _________________________________ Address: _________________________________________________

Parent/Guardian #2

Name: ___________________________________________________________ Relationship to child: _____________________

Address: _________________________________________________________________________________________________

Home Phone: _______________________ Work Phone: _______________________ Cell Phone: _______________________

Email address: ____________________________________________________________________________________________

Employer Name: _________________________________ Address: _________________________________________________

Emergency Contact and Release Information –

If possible please notify the site if an Emergency Release Person will pick up your child on a given day. For the safety

of your child, we will request all authorized pick up people with whom staff are not familiar to provide a Government issued photo ID at time of pick up.

Emergency Contact #3

Name: ___________________________________________________________ Relationship to child: _____________________

Address: _________________________________________________________________________________________________

Home Phone: _______________________ Work Phone: _______________________ Cell Phone: _______________________

Email address: ____________________________________________________________________________________________

Emergency Contact #4

Name: ___________________________________________________________ Relationship to child: _____________________

Address: _________________________________________________________________________________________________

Home Phone: _______________________ Work Phone: _______________________ Cell Phone: _______________________

Email address: ____________________________________________________________________________________________

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Any additional Emergency Contacts or Authorized Pick up people indicate on back of form, include name, address, and phone number.

The persons designated in this section will be contacted by Peace and are authorized to pick up your child if there is a medical or other emergency and you cannot be reached. In addition, release person must

be 18 years of age or older. Site staff will release your child only to you or those persons you have listed above. Emergencies may prevent you from picking up your child; therefore, include those individuals

whom you would authorize in such events. If you want a person who is not identified above you must notify site staff in advance, in writing. Your child will not be released without prior authorization.

Please indicate hours of childcare needed:

Enrollment Start Date:

Weekday

Monday

Tuesday

Wednesday

Thursday

Friday

Hours

Month / Day / Year

*Peace Childcare Learning Center is affiliated with Peace Lutheran Church and School. Children will be taught according to the vision of Peace Ministries:

“Peace Lutheran will nurture and educate families in our community, beginning with children, so that they live abundant lives in Christ.”