Annual Registration & Medical Release

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Which location fits your family best?

We only provide staff supervised pick-up from certain schools, but you can always have your student walk or request bus transportation from your student's school to our facility.

Glencliff (149 Antioch Pike)

Glencliff Elementary (Staff supervised pick-up)

Wright Middle School (Easy walk distance)

Glencliff High School (Easy walk distance)

Madison (301 Woodruff St.)

Taylor Stratton Elementary (Staff supervised pick-up)

Madison Middle (Easy walk distance)

Tusculum (4908 Aquatic Rd.)

Tusculum Elementary (Staff supervised pick-up)

Haywood Elementary (Staff supervised pick-up)

Fall Hamilton Elementary (Staff supervised pick-up)

Hit next to let us know which location works best for your family.
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Location* This field is required.
Glencliff
Madison
Tusculum
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Student's Name* This field is required.
First Name
Last Name
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Birth Date* This field is required.
Month
Day
Year
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Age* This field is required.
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Grade* This field is required.What grade will your child be in for the school year this will apply to? This should not be the grade they have completed.
If in Kindergarten use the number 0
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Gender* This field is required.
Male
Female
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School* This field is required.If your student doesn't attend any of the listed schools please type in your student's school in the other box.
Fall Hamilton Elementary
Glencliff Elementary
Taylor Stratton Elementary
Tusculum Elementary
Glencliff High School
Wright Middle School
Madison Middle School
Other
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Teacher's Name
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Who has legal custody?* This field is required.Choose "Mom" if ONLY mom has custody. If Dad also has custody then choose "Mom and Dad."
Mom
Mom and Dad
Dad
Other
11
Are both parents at the home address?* This field is required.
YESNO
12
Can both parents pick up this child?* This field is required.
YESNO
13
Does this child have permission to walk home?* This field is required.
YESNO
14
List any allergies, mental health or medical condition.* This field is required.Please keep us informed as your student's health changes throughout the year. Consider allergies to medicines as well.
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My child's immunization records are on file at the school.* This field is required.
YESNO
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Physician's Name* This field is required.
First Name
Last Name
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Physician's Phone Number* This field is required.
Area Code
Phone Number
18
Do you have healthcare?* This field is required.Including TennCare
YESNO
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Who is your healthcare through?* This field is required.
20
Preferred Hospital* This field is required.In the event that hospitalization is necessary, I prefer my child be sent to this hospital:
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Is your child taking any medicine?* This field is required.
YESNO
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What medication is your child taking?* This field is required.Please be as specific as possible. Consider the event that you cannot be immediately reached in an emergency. We need to provide the medical professionals this information.
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Is your child able to play as hard as other children their age?* This field is required.
YESNO
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Why isn't your child able to play as hard as other children?
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Has your child ever been in the hospital overnight, had surgery or a serious illness?* This field is required.
YESNO
26
Any allergies or reactions to medicine, DPT or other shots, or insects?* This field is required.
YESNO
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What kind of allergy reaction to medicine, DPT or other shots, or insects?
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Has your child had asthma or wheezing?* This field is required.
YESNO
29
Does your child have speech or hearing problems?* This field is required.
YESNO
30
Does your child have trouble with his/her eyes or seeing?* This field is required.
YESNO
31
Has your child has a bladder or kidney infection?* This field is required.
YESNO
32
Does he/she have seizures, fits or shaking spells?* This field is required.
YESNO
33
Have you ever been told your child has a heart murmur, a heart defect or heart disease?* This field is required.
YESNO
34
Has your child ever had a bumpy, swollen reaction to the Tuberculosis skin test?* This field is required.
YESNO
35
Has your child been around anyone having Tuberculosis?* This field is required.
YESNO
36
Is your child a hemophiliac?* This field is required.
YESNO
37
Does your child have hepatitis?* This field is required.
YESNO
38
Is your child Human Immunodeficiency Virus (HIV) positive?* This field is required.
YESNO
39
Does your child have tubes in his/her ears?* This field is required.
YESNO
40
Does your child have a hernia?* This field is required.
YESNO
41
Does your child have frequent ear infections?* This field is required.
YESNO
42
Does your child have diabetes?* This field is required.
YESNO
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Does your child have high blood pressure?* This field is required.
YESNO
44
Does your child have dizzy spells or headaches?* This field is required.
YESNO
45
Does your child have skin problems?* This field is required.
YESNO
46
Has your child ever had a broken bone(s), dislocated joints or serious sprains?* This field is required.
YESNO
47
Please describe the injury and give a date.
48
Does your child have chronic or recurring illness?* This field is required.
YESNO
49
Please describe the illness.
50
Is your child in special education?* This field is required.
YESNO
51
Please describe how special education benefits your child.
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Does your child have any special problems not indicated above?* This field is required.
YESNO
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What other special problems have not indicated above?* This field is required.
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Chicken Pox Vaccination Date:* This field is required.
Date
Year
Month
Day
55
Measles Vaccination Date:* This field is required.
Date
Year
Month
Day
56
Mumps Vaccination Date:* This field is required.
Date
Year
Month
Day
57
German Measles Vaccination Date:* This field is required.
Date
Year
Month
Day
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Primary Custodial Guardian Name* This field is required.
First Name
Last Name
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Primary Custodial Guardian Phone* This field is required.If your number changes let us know!
Area Code
Phone Number
60
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
United States
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
61
Who else lives at this address?* This field is required.Please be sure to include gender and age.
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Primary Custodial Guardian Email* This field is required.
example@example.com
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Primary Custodial Guardian Employer* This field is required.
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Primary Custodial Guardian Work Hours* This field is required.We want to be able to contact you at a time that is good for your work schedule (Ex. Monday-Friday, 8am-5pm).
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Secondary Custodial Guardian Name
First Name
Last Name
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Secondary Custodial Guardian Phone
Area Code
Phone Number
67
Secondary Custodial Guardian Email
example@example.com
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Emergency Contact Name* This field is required.Imagine that you are incapacitated. Who should I call to care for your kid/s?
First Name
Last Name
69
Emergency Contact Phone* This field is required.
Area Code
Phone Number
70
In addition to the people listed above, who else can pickup your child from Cottage Cove?* This field is required.Please include a full name so that we can check the Drivers License of someone we don't recognize.
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71
I hereby give my permission to the physician selected by Cottage Cove to order X-rays, routine tests, and treatment for the health of my child. In the event I cannot be reached in an emergency, I give permission to the physician selected by Cottage Cove to hospitalize, secure proper treatment for, and order injection and/or anesthesia and/or surgery for my child as named above. In the event it becomes necessary for the Cottage Cove staff to give consent for us, we agree to hold such person and Cottage Cove free and harmless of any claims, demands, or suits for damages arising from the giving of such consent, so long as the treatment is administered by or under the supervision of a licensed physician. I realize that Cottage Cove does not carry accident insurance on program participants. I also realize that I am responsible for all insurance and/or out of pocket expenses. Wherein my child is permitted to attend Cottage Cove’s program, I understand that I must sign additional releases and waivers covering image usage, transportation, and information transfer between my child’s school and Cottage Cove. Also, an annual written or verbal statement (recorded) may be required as to how this program is benefiting my child and/or family.Please type your full name below to acknowledge the releases above.
72
I hereby give my permission to the physician selected by Cottage Cove to order X-rays, routine tests, and treatment for the health of my child. In the event I cannot be reached in an emergency, I give permission to the physician selected by Cottage Cove to hospitalize, secure proper treatment for, and order injection and/or anesthesia and/or surgery for my child as named above. In the event it becomes necessary for the Cottage Cove staff to give consent for us, we agree to hold such person and Cottage Cove free and harmless of any claims, demands, or suits for damages arising from the giving of such consent, so long as the treatment is administered by or under the supervision of a licensed physician. I realize that Cottage Cove does not carry accident insurance on program participants. I also realize that I am responsible for all insurance and/or out of pocket expenses. Wherein my child is permitted to attend Cottage Cove’s program, I understand that I must sign additional releases and waivers covering image usage, transportation, and information transfer between my child’s school and Cottage Cove. Also an annual written or verbal statement (recorded) may be required as to how this program is benefiting my child and/or family.
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Which location fits your family best?