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Riverton High Child Care Registration
Please contact Launa Jones to assure availability 801-256-5851
Child's Name *
Your answer
Birthday *
MM
/
DD
/
YYYY
Gender *
Required
Home phone number
Child's home address *
Your answer
Additional Child's name (if more than one child is coming to child care)
Your answer
Additional child's birth date
Your answer
Mother's Name *
Your answer
Mother's cell phone number *
Your answer
Mother's work phone number *
Your answer
Father's Name *
Your answer
Father's cell phone number *
Your answer
Father's work phone number *
Your answer
parent's preferred email address *
Your answer
In case of a custodial issue, please inform the Child Care Manager and make a note on this record.
Your answer
1)Emergency Contact First and Last Name *
Your answer
1)Relation to child *
Your answer
1)Emergency Contact phone number *
Your answer
2)Emergency Contact First and Last Name *
Your answer
2)Relation to child *
Your answer
2)Emergency Contact Phone Number *
Your answer
Child's Physician Name
Your answer
Physician's phone number
Your answer
Physician's address
Your answer
Hospital Preference
Your answer
HEALTH AND PERSONAL INFORMATION
Select child's schedule for the upcoming year*
Please list child's schedule in detail if not full time.
Your answer
Does your child have any physical problems of which we should be aware of? If yes, explain
Your answer
Does your child take any prescription medication on a regular basis? If yes, explain.
Your answer
Does your child have any allergies? If yes, please list below.
Your answer
Are there any special family circumstances which may be a factor in your child's present behavior? (divorce, death, new baby, recent move, hospitalization, etc. Please explain.
Your answer
Do you have any concerns about your child's present behavior? If yes, explain.
Your answer
Please list siblings name, gender, and age in order of oldest to youngest. (include your child) Example: Spencer, M, 10
Your answer
List your child's favorite color.
Your answer
List your child's favorite food.
Your answer
List child's favorite toy.
Your answer
List child's favorite book.
Your answer
List child's favorite TV show/movie.
Your answer
Additional child's favorite color.
Your answer
Additional child's favorite food.
Your answer
Additional child's favorite toy.
Your answer
Additional child's favorite book.
Your answer
Additional child's favorite tv show/movie.
Your answer
Does your child have a special security/comfort items - Blankie, stuffed animal, binkies, etc.? If yes, please list it and whether or not your child will need to bring it each day.
Your answer
DEPARTMENT PERMISSION FORM
I hereby give permission for my child to leave the Riverton High School Child Care lab only with the person(s) named below. Picture identification will be required. My child will not be allowed to leave the premises with any person(s) not on this list. It is my responsibility to notify the center, in writing, of any changes.
1)First and Last Name
Your answer
1)Relation to the child
Your answer
2)First and Last Name
Your answer
2)Relation to the child
Your answer
3)First and Last Name
Your answer
3)Relation to child
Your answer
4)First and Last Name
Your answer
4) Relation to child
Your answer
In a situation where there is a custodial issue, we must have legal documentation to show guardianship. We need this to prevent an unauthorized person from visiting or picking up a child. If there is a separation or divorce custody problem, of which we should be made aware, please explain below.
Your answer
Name of person(s) who MAY NOT pick up child
Your answer
I understand in addition to this registration form, I must also sign the Parent Consent Agreement before my child may attend Riverton High Child Care Lab.
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