Infant Enrollment Forms

NDIIS PERMISSION FORM
Through the North Dakota Immunization Information System (NDIIS), with written parental permission, Active Minds Academy may access you child’s immunization records. All records are kept confidential and the only AMA Employees with access to the system is the owner or director. Pease see the paragraph below for information on Active Minds Academy’s Immunization Policy.

Active Minds Immunization Policy

All enrolled children are required to be fully up-to-date with their immunizations with the exception of those with a signed medical exception from a physician. A copy of your child’s immunizations is required to be turned in and kept on file throughout your child’s enrollment at Active Minds Academy. Out of date immunizations will cause a suspension in care.

*Immunization information is only available if immunizations are received within the state of North Dakota, any immunizations received out of state must be turned in by the child’s parents or guardians.
Child's Name: *

First Name Last Name
Child's DOB: *

Month Day Year
Date
Parent/Guardian Authorization: *

I DO grant Active Minds Academy permission to have access to my child's immunization records via NDIIS. I DO NOT give Active Minds Academy permission to have access to my child's immunization records via NDIIS. I will provide up to date immunizations myself.
Parent/Guardian Name: *

First Name Last Name
Parent/Guardian Signature: *

Clear
Date: *

Month Day Year
Date
If your family choose NOT to allow Active Minds Academy access to your child's immunization records OR your child was immunized in another state, please upload a copy of your child's current immunization records below:

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AUTHORIZATION FOR NON-PRESCRIPTION PRODUCTS
All over the counter products require written parental permission on a yearly basis. The following products may be applied to my child in accordance with the manufacturer’s instructions on the original container.

This form will be completed on a yearly basis.
Child's Name: *

First Name Last Name
Child's DOB: *

Month Day Year
Date
The following products may be used for my child:

Diaper Cream/Ointment Skin Lotion Lip Balm Sunscreen (6+ months) Insect Repellent (2+ months) Antibacterial First Aid Ointment Tooth Paste
Parent/Guardian Name: *

First Name Last Name
Parent/Guardian Signature: *

Clear
Date *

Month Day Year
Date
Parent/Guardian Name:

First Name Last Name
Parent/Guardian Signature:

Clear
Date

Month Day Year
Date

AQUATIC ACTIVITY PERMISSION FORM
Child's Name: *

First Name Last Name
Child's DOB: *

Month Day Year
Date
I understand that Active Minds Academy will maintain a safe staff to child ratio while participating in aquatic activities and closely monitor my child. Children will never be left unattended.
My child may participate in:

Swimming in on-site Wading Pools Water Table play Splash Pad Sprinklers
Please best describe your child's swimming abilities. My child is:

A non-swimmer Has successfully completed formal swimming lessons, please describe below. Has special needs with water activities, please describe below.
Details:
I hearby give consent for my child to participate in water activities while enrolled at Active Minds Academy.

This form will be completed on a yearly basis.
Parent/Guardian Name: *

First Name Last Name
Parent/Guardian Signature: *

Clear
Date: *

Month Day Year
Date
Parent/Guardian Name:

First Name Last Name
Parent/Guardian Signature:

Clear
Date:

Month Day Year
Date

INFANT SLEEP PERMISSION FORM
With written parental permission, the provider may place one individual blanket or sleep sack, a pacifier, and one security item that does not pose a risk of suffocation to the infant in the crib or pack and play while the infant is sleeping or preparing to sleep.

The American Academy of Pediatrics recommends keeping soft objects and loose bedding (including blankets) out of the crib or pack and play to reduce the risk of SIDS, suffocuation, entrapment, and stragulation for infants under the age of 12 months. The AAP recommends the use of pacifiers for sleep. Studies have reported a protective effect of pacifiers on the incidents of SIDS. Pacifiers are checked for tears before each use.
Blankets:
- A written order from a health care provider is required to use more than one blanket.
- If an infant is being swaddled, the blanket should no come any higher than to the shoulders of the infant. In addition, the blanket needs to be loose enough for a hand to fit between the blanket and the infant's chest. The blanket should be keep loose around the infant's hips.
- Swaddling is recommended, by the AAP, to be discountinued once the infant reaches two months of age, or sooner if the infant is showing signs of rolling.
- North Dakota State Licensing Regulations requires swaddling to be discountinued one an infant becomes mobile.
- A written order from a health care provider is required to continue swaddling after an infant becomes mobile.
Sleep Sacks:
- Swaddle sleep sacks (with arm panels) are reecommended to be discontinued once an infant reaches two months of age, or sooner if the infant is showing signs of rolling. Once the infant is showing signs of rolling or reaches two months of age, sleeveless sleep sacks should be used.
Pacifiers:
- Pacifiers are not allowed to be attached to a clip or strap.
- Pacifiers attached to a stuffed animal or toy are not to be used within the center.
Security Items:
- Necklaces, including teething necklaces, are not allowed.
- Bibs are not to be worn while sleeping.
- Headbands are to be removed while sleeping.
Child's Name: *

First Name Last Name
I have read the above stated information and give Active Minds Academy permission to use the following checked items when my infant is sleeping or preparing to sleep:

Blanket Sleep Sack Pacifier Security Item
If checked, please describe security item:
Parent/Guardian Name: *

First Name Last Name
Parent/Guardian Signature: *

Clear
Date: *

Month Day Year
Date
Parent/Guardian Name:

First Name Last Name
Parent/Guardian Signature:

Clear
Date:

Month Day Year
Date

SFN 845: CHILD INFORMATION SHEET

This form is required by the State of North Dakota and is required to be completed on a yearly basis.
Child Information:
First Name *
Preferred Name or Nickname:
Middle Name: *
Last Name: *
Child's DOB: *

Month Day Year
Date
Date of Enrollment: *

Month Day Year
Date
Parent/Guardian #1 Information:
Name: *

First Name Last Name
Home Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone Number: *

Area Code Phone Number
Cell Phone Number: *

Area Code Phone Number
Place of Employment: *
Hours of Employment: *
Example: 7am-4pm
Work Phone Number: *

Area Code Phone Number
Parent/Guardian #2 Information:
Name:

First Name Last Name
Home Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone Number:

Area Code Phone Number
Cell Phone Number:

Area Code Phone Number
Place of Employment:
Hours of Employment:
Example: 7am-4pm
Work Phone Number:

Area Code Phone Number
Emergency Authorization:

In case of an emergency and parents cannot be reached, who should be contacted?
Emergency Contact Name: *
Relationship to Child: *
Cell Phone Number: *

Area Code Phone Number
Work Phone Number:

Area Code Phone Number
Emergency Contact Name: *
Relationship to Child: *
Cell Phone Number: *

Area Code Phone Number
Work Phone Number:

Area Code Phone Number
Physician to Call in an Emergency: *

First Name Last Name
Clinic Phone Number: *

Area Code Phone Number
Dentist to Call in an Emergency: *

First Name Last Name
Office Phone Number: *

Area Code Phone Number
I hearby authorize the Early Childhood Program to secure emergency medical treatment for my child under the follwoing conditions:
1. An emergency or unanticipated condition necessitates immediate action for the presservation of the life or health of the child, and
2. Reasonable attempts to contact me have failed.
Parent/Guardian Signature: *

Clear
Date *

Month Day Year
Date
Parent/Guardian Signature:

Clear
Date

Month Day Year
Date
Authorization to Release Child:

Unless otherwise authorized by you in writing, only the parent or legal guardian may pick up your child(ren) from the Early Childhood Program. List below any others you wish to authorize for this purpose.
Name:
Relationship to Child:
Phone Number:

Area Code Phone Number
Name:
Relationship to Child:
Phone Number:

Area Code Phone Number
Name:
Relationship to Child:
Phone Number:

Area Code Phone Number
The people listed below are NOT allowed to pick up my child:
Name:
Relationship to Child:
Name:
Relationship to Child:
The State of North Dakota requires childcare centers to verify the identification of all children enrolled. Options of verification include: A copy of your child's birth certificate, passport, adoption decree, etc. Please upload a copy of one of these documents below:

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Cancel of

NDIIS PERMISSION FORM

CHILD INFORMATION

Typical Weekly Schedule:

Medical Information:

AUTHORIZATION FOR NON-PRESCRIPTION PRODUCTS

AQUATIC ACTIVITY PERMISSION FORM

INFANT SLEEP PERMISSION FORM

INFANT SOCIAL RESUME

Child Information:

Family Information:

Feeding Information:

Sleep Information:

Understanding Your Child:

SFN 845: CHILD INFORMATION SHEET

Child Information:

Parent/Guardian #1 Information:

Parent/Guardian #2 Information:

Emergency Authorization:

Authorization to Release Child:

SFN 847: PARENT'S STATEMENT ON HEALTH OF CHILD

Child Information:

Parent/Guardian Information:

Medical Information: