SSA Enrollment Application

Smart Starters Academy Child Care Learning Center

Child Enrollment Information
Child's Name*
Date of Birth *

MonthDayYear
Age
Sex

BoyGirl
Parent's/Guardian's Name (1)*
Parent's/Guardian's Name (2)*
Home Phone Number*
Please enter a valid phone number.
Home Phone Number *
Please enter a valid phone number.
Home Address*

Street Address

Street Address Line 2

CityState / Province

City, State & ZIP Code
Home Address*

Street Address

Street Address Line 2

CityState / Province

City, State & ZIP Code
Work Phone*
Please enter a valid phone number.
Work Phone*
Please enter a valid phone number.
Parent's/Guardian (1) Work Address*

Street Address

Street Address Line 2

CityState / Province

City, State & ZIP Code
Parent's/Guardian (2) Work Address*

Street Address

Street Address Line 2

CityState / Province

City, State & ZIP Code
Email *
example@example.com
Email
example@example.com
Alternative Emergency Contacts
Primary Emergency Contact
Secondary Emergency Contact
Relationship to Child
Relationship to Child
Phone Number
Please enter a valid phone number.
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

City, State & ZIP Code
Address

Street Address

Street Address Line 2

CityState / Province

City, State & ZIP Code
Medical Information / Authorization to Receive Medical Treatment
Hospital/Clinic Preference
Physician's Name
Phone Number
Please enter a valid phone number.
Insurance Company
Policy Number
Allergies/Special Health Considerations
Parent's/Guardian's Signature
Date

MonthDayYear
Permission to Take Child off the Premises
I give permission for my child, to go off the premises with Chantelle Hester and/or Linton Hester. The off premises includes emergency evacuation to a nearby provider in the neighborhood in the proper seating equipment (single/multi seat stroller). I release Smart Starters Academy Child Care Learning Center and the abovementioned individuals from liability in case of injury during the related emergency evacuation plan as long as normal safety procedures have been taken.
Parent's/Guardian's Signature
Date

MonthDayYear
Witness Signature
Date

MonthDayYear
Authorization to Dispense Medication
Except for first aid we, Chantelle Hester, Linton Hester and other helpers will not hand out prescription or nonprescription medication to a child without specific written authorization from the child's physician or parent. All medications will be stored in accordance with the prescription or label instructions and kept in places that are inaccessible to children. Each dose of medication given to a child will be documented showing the child's name, name of medication as well as date and time given.

I authorize Chantelle Hester, Linton Hester and/or other helpers to administer the below mentioned medication to my child.
Child's Full Name
Name of Medication:
RX Number:
Medication Purpose:
Dosage:
Time of Day Medication is to be Given:
Any other Comments and/or Instructions:
Parent/Guardian Notice of No Liability Insurance and Acknowledgment
I understand that I am being informed in writing by signing this acknowledgment that this child care center does not carry liability insurance sufficient to protect my children in the event of an injury, etc.
Parents'/Guardians' Signature (1)

Clear
Parents'/Guardians' Signature (2)

Clear
Print Name
Print Name
Date

MonthDayYear
Date

MonthDayYear
Social Media & Photos
I am signing this form acknowledging that I have been asked and have granted permission to my childcare provider to be able to use photos of my child(ren) to post on social media for business advertisement purposes only. I am aware that if I have any questions or concerns, I may discuss them with my childcare provider.
Parents'/Guardians' Signature (1)

Clear
Parents'/Guardians' Signature (2)

Clear
Print Name
Print Name
Date

MonthDayYear
Date

MonthDayYear
Chantelle R. Hester, MPA, TCC, Childcare Provider
Date

MonthDayYear
Should be Empty:

Smart Starters Academy Child Care Learning Center

Alternative Emergency Contacts

Medical Information / Authorization to Receive Medical Treatment

Permission to Take Child off the Premises

Authorization to Dispense Medication

Parent/Guardian Notice of No Liability Insurance and Acknowledgment

Social Media & Photos