Daycare Tuition Program Enrollment Form Page 2

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This form allows parents and guardians to authorize the provision of emergency treatment for below named child who becomes ill or injured while
under program authority when parents or guardians cannot be reached.
In the event reasonable attempts to contact have been unsuccessful, I hereby give consent for the administration of any treatment deemed
necessary by the doctor or dentist listed below, or if unavailable, another licensed physician or dentist.
I agree to pay all costs and fees as secured or authorized under this consent.
CHILD’S NAME:
BIRTH DATE:
PARENT(S)/GUARDIAN(S) WITH WHOM THE CHILD RESIDES
1. NAME
RELATIONSHIP TO CHILD
ADDRESS
EMPLOYER
HOME NUMBER
CELL NUMBER
WORK NUMBER
2. NAME
RELATIONSHIP TO CHILD
ADDRESS
EMPLOYER
HOME NUMBER
CELL NUMBER
WORK NUMBER
EMERGENCY CONTACT PERSON(S)
1. NAME
RELATIONSHIP TO CHILD
HOME NUMBER
CELL NUMBER
WORK NUMBER
2. NAME
RELATIONSHIP TO CHILD
HOME NUMBER
CELL NUMBER
WORK NUMBER
3. NAME
RELATIONSHIP TO CHILD
HOME NUMBER
CELL NUMBER
WORK NUMBER
PERSONS AUTHORIZED TO PICK UP CHILD
ADDRESS
PHONE NUMBER
1.
2.
3.
Are there any custody or restraining orders for person(s) who may attempt to pick up or have contact with the child while in
care at the center?
Name
Name
PHYSICIAN NAME
DENTIST NAME
PHONE NUMBER
PHONE NUMBER
ADDRESS
ADDRESS
HOSPITAL PREFERENCE
KNOWN ALLERGIES
DATE OF LAST TETANUS
PRESENT MEDICATION
INSURANCE COMPANY
POLICY HOLDER ID
This consent will be in effect for one year beginning (date)
SIGNATURE OF PARENT OR GUARDIAN
DATE
SIGNATURE OF PARENT OR GUARDIAN
DATE

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