Harris Creek Parent's Day Out and Preschool Enrollment Form 2020-2021
Email address *
Days Applying For (choose all that apply): *
Required
CHILD'S INFORMATION
First Name: *
Your answer
Middle Name: *
Your answer
Last Name: *
Your answer
Nickname or other name the child goes by:
Your answer
Birthday: *
MM
/
DD
/
YYYY
Child lives with: *
PARENT'S INFORMATION
Parents are: *
If divorced, who has legal custody?:
May the non-custodial parent pick up the child? **If no, you must provide legal documentation.:
Mother's Full Name: *
Your answer
Mother's Address (street address, city, state, zip code): *
Your answer
Mother's Cell Phone Number: *
Your answer
Mother's Email Address: *
Your answer
Mother's Employer:
Your answer
Church Membership:
Your answer
Father's Full Name: *
Your answer
Father's Address (if different from Mother's) (street address, city, state, zip code):
Your answer
Father's Cell Phone Number: *
Your answer
Father's Email Address: *
Your answer
Father's Employer:
Your answer
Church Membership:
Your answer
Legal Guardian's Name (if applicable):
Your answer
Legal Guardian's Address (street address, city, state, zip code):
Your answer
Legal Guardian's Cell Phone Number:
Your answer
Legal Guardian's Email Address:
Your answer
EMERGENCY CONTACTS
Name two people who would assume responsibility for your child if you cannot be reached.
Full Name: *
Your answer
Phone Number: *
Your answer
Relationship to child: *
Your answer
Full Name: *
Your answer
Phone Number: *
Your answer
Relationship to child: *
Your answer
AUTHORIZED PICK-UPS
I hereby authorize Harris Creek Baptist Church to allow my child to leave the facility with ONLY the following persons (these are in addition to the Emergency Contacts).
Full Name:
Your answer
Phone Number:
Your answer
Relationship to child:
Your answer
Full Name:
Your answer
Phone Number:
Your answer
Relationship to child:
Your answer
Full Name:
Your answer
Phone Number:
Your answer
Relationship to child:
Your answer
Full Name:
Your answer
Phone Number:
Your answer
Relationship to child:
Your answer
I understand that my child will only be released from Harris Creek Baptist Church to me or a person on this list. If someone who is not on this pick up list comes for my child, I will notify Harris Creek Baptist Church in advance by phone or in person, and the person must have picture identification. I also understand that any person delivering or picking up my child must make staff members aware of my child’s arrival and/or departure. *
Required
ACKNOWLEDGEMENT OF POLICIES AND PROCEDURES
I have read and understand the Harris Creek Parent’s Day Out and Preschool PARENT HANDBOOK. In order to keep my child enrolled at Harris Creek Baptist Church, I agree to abide by these policies. Harris Creek Parent’s Day Out and Preschool has the right to refuse admission to anyone. I understand the importance of making timely tuition payments and using good judgment when determining whether to keep my child home if he or she should become ill. *
Required
EMERGENCY TRANSPORTATION
I give Harris Creek Baptist Church permission to transport my child to a safe location in the event of a medical emergency or an emergency evacuation. I understand that I may or may not be notified in advance of such transportation. *
Required
FIELD TRIPS
I give Harris Creek Baptist Church permission for my child to participate in excursions or other planned trips away from the church, so long as the church has provided advance notice for the activity. *
Required
WATER ACTIVITIES
I give permission for my child to participate in supervised water activities while at Harris Creek Baptist Church. Such activities may include sprinkler play, water table play, or wading pool play. *
Required
MEDIA RELEASE
I give permission for my child’s image to be displayed on the Harris Creek Baptist Church website and in other promotional materials. I understand that this material may be used for informational purposes within the church and may also be used to provide information about programs and activities to the public through publications, displays, in newspapers and other print media. *
Required
MEDICAL INFORMATION
In the event that I cannot be reached to make arrangements for emergency medical attention, I authorize the person in charge at Harris Creek Baptist Church to take my child to:
Name of Physician: *
Your answer
Phone Number: *
Your answer
Name of Preferred Hospital: *
Your answer
Insurance Company Name:
Your answer
Policy Number: *
Your answer
Phone Number: *
Your answer
I give consent for this facility to secure any and all necessary emergency medical care when my child is in the care of this physician and/or hospital or clinic. *
Required
MEDICAL HISTORY
Please list any special needs or problems that your child has including allergies (food, medication, etc.), existing illnesses, previous serious illnesses, or serious injuries that we should be made aware of. Also include any hospitalizations during the past 12 months, and any medication prescribed for continuous, long-term use. Please write N/A if inapplicable.
Your answer
A copy of your responses will be emailed to the address you provided.
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