Registration Form

Child’s Name * Age *

Birth Date * Gender *

Child’s Address * City

Child Lives with * :

Other

Person to call first

Please mark your choice of program below:*

Preschool Programming:

Opened on:

Monthly Subscription

Mondays till Fridays

Mondays

Full Time (7:00AM-5 :00PM): $340

Tuesdays

Part Time (7:00AM-3:00PM): $300

Wednesdays

Mondays Till Saturdays

Thursdays

Full Time (7:00AM-5:00PM): $400

Fridays

Part Time (7:00AM-3:00PM): $360

Saturdays (7:00 AM-2:30PM)

Yearly Subscription

$

Parent/Guardian Information

1.
Adult Name *

Relation to child *

Home address and City *

Home Phone *Work Phone

Cell Phone *

Employed by *

E-Mail *

2.
Adult Name

Relation to child

Home address and City

Home Phone Work Phone

Cell Phone

Employed by

E-Mail

Emergency Contact (Other than the parent/guardian, local name we can contact if we are unable to reach you)

1.
Name *

Relation to child *

Home Address and City *

Home Phone Work Phone

Cell Phone

2.
Name

Relation to child

Home Address and City

Home Phone Work Phone

Cell Phone

Persons authorized to pick up my child.

1.
Name *

Home Phone Cell Phone *

Relation to child *

2.
Name

Home Phone Cell Phone

Relation to child

Who does not have permission to pick up your child?

Name Reason

Name Reason

We do not release a child without prior notification. Persons you authorize are required to show ID.

Insurance Company

Group #

Policy #

Policy Holder Name

Employer Name

Emergency/Health Information

Physician Phone

Last physical was on

Address and City

Dentist Phone

Last dentist apt was on

Address and City

Child’s Blood Type

Allergies, medications, physical or food restrictions? If none, please write NONE

What additional information should ANGEL’S KIDS nursery be aware of if your child comes in contact with the allergen?

Please describe any specific health or emotional problems or pertinent family background information which ANGEL’S KIDS nursery should be aware of

ANGEL’S KIDS nursery requires all medication taken by the child to be listed below:

Does your child have any disabilities or health concerns that will affect his or her ability to participate in activities?

Please mark below if your child has any of the following medical conditions: *

Asthma

Diabetes

Eczema

Epilepsy

Fainting Spells

Frequent colds

Frequent ear infections

Frequent sore throats

Frequent nose bleeds

Heart concerns

Problems with diarrhea

Problems with constipation

Stomach upsets

Urinary problems

Other:

Copy of Child’s medical report is requested for the file. This should be updated after each visit to the physician.

Important Notices :

1. ANGEL’S KIDS nursery will immediately notify parents if their kid’s temperature is 38°C after the daily temperature check.
Parents are then required to pick up the child for the day.

2. Children admitted with 38°C temperature will not be taken in for the day in order not to spread contamination among the other kids.

3. Children on antibiotic treatments will not be admitted before 48 hours of treatment’s commencement

Consent to medical care and treatment of minor children

I give permission that my child, * , may be given first aid/emergency treatment by a qualified child care provider and/or staff at ANGEL’S KIDS nursery.

When I cannot be contacted, I authorize and consent to medical, surgical and hospital care, treatment and procedures to be performed for my child by a licensed physician, or hospital when deemed necessary or advisable by the physician or aid care attendant to safeguard my child’s health.

I also give permission for my child to be transported by ambulance to an emergency center for treatment. I certify under penalty of perjury under the local laws that this information is true and correct.

Parent/Guardian Signature *

Date *