FAMILY CHILDCARE REGISTRATION and EMERGENCY RELEASE

Child’s Full Name ___________________________________Nickname_____________

Birth Date:_____________________________Date of Enrollment_________________

Address:______________________________________________________________

City______________________________State____________Zip Code_____________

Home Phone__________________

Mother’s Full Name______________________________________________________

Mother’s Address:_______________________________________________________

City______________________________State____________Zip Code_____________

Mother’s Home Phone____________________________________________________

Mother’s Employer_______________________________________________________

Employer’s Address_______________________________City___________State_____

Mothers Occupation:_____________________________________________________

Hours at work:_______ to ______.   Days at work:______________________________

Work Phone:_________ ext.____ Pager or Cell #_______________________________

Father's Full Name:______________________________________________________

Father’s Address________________________________________________________

City____________________________State_______________Zip Code____________

Father’s Home Phone_____________________________________________________

Father’s Employer_______________________________________________________

Employer’s Address_______________________________City___________State_____

Father’s Occupation:_____________________________________________________

Hours at work:______ to ______.   Days at work:_______________________________

Work Phone:_________ ext.____ Pager or Cell #_______________________________

(Next Section Fill out only if applicable)

Parent/Guardian with legal custody:_______________Decree on file?  Yes  or  No (circle)

Parents are: Married /Divorced / Separated /Widowed /Single

Emergency Contact Information

Primary Emergency Contact(other than parents/guardian):

Name________________________________________________________________

Home Phone:___________________________Work Phone:______________________

Emergency Contact Address_____________________City__________State________

Relationship to Child:____________________________________________________

Secondary Emergency Contact(other than parents/guardian):

Name________________________________________________________________

Home Phone:____________________________Work Phone______________________

Second Emergency contact address:___________City_____________State__________

Relationship to Child_____________________________________________________

Person(s) authorized to pick up my child(Besides parents/guardians or emergency contacts:

#1___________________________________________________________________

#2__________________________________________________________________

#3__________________________________________________________________

(With prior notice from parent/guardian and proper ID only)

Daycare References (optional):

Has your child ever been in daycare before?___________________________________

If so, why did you leave?__________________________________________________

Name of Previous Provider:________________________________________________

Phone number of Previous Provider:__________________________________________

Emergency Release

Consent to Emergency First Aid & Transportation

I hereby give my permission that my child, may be given emergency treatment by By God’s Grace staff. I also give permission for my child to be transported by car or ambulance to an emergency center for treatment.

Parent/Guardian Signatures:________________________  ______________________

Date______________

Consent to Medical Care and Treatment

In the event that I cannot be contacted immediately, medical or surgical treatment can be administered to my child in the case of an accident or emergency, as prescribed by a treating physician.

Parents/Guardians Signatures:______________________________________________ Date:____________

By God’s Grace Daycare or staff will not be responsible for paying for the child's health care.

1. Child's Physician:___________________________ Phone:______________________

2. Preferred Hospital:_________________________ Phone:______________________

3. Insurance Company:_________________________ Policy #____________________

4. Regular Medications:___________________________________________________

5. Blood Type:__________

6. Medicine allergic to:___________________________________________________

7. Food Allergies:_______________________________________________________

8. Any other Allergies:___________________________________________________

9. Any special health conditions:____________________________________________

Overview Of Care Needs

Number of days per week child care is needed:_________________________________

Days of week care is needed:_______________________________________________

I will bring my child to day care at:___ AM/___PM

I will pick up my child:___ AM/___PM.......Weekly fee:_____Late fee:________________

A last weeks fee / security deposit of: $____________ must accompany this registration.

(This fee will be applied to your child's final bill.)

Comments:

Signatures:

Parent/Guardian:_________________________________Date:___________________

Parent/Guardian_________________________________Date:___________________

(I understand that this is a legally binding document, and have read it and understand it)