Fall Registration Form
858 East Broadway lifekidsdirector@gmail.com 940-256-2502
Child
*
Birthdate
*
/
Month
/
Day
Year
Date
Sex:
*
Male
Female
Child's Address
*
Full name of Mother
*
Email
*
example@example.com
Mother's Address
*
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
ext.
Cell Phone
*
Format: (000) 000-0000.
Place of work
Full name of Father
Father's Address: Same
Full name of Father
Email
example@example.com
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
ext.
Cell Phone
Format: (000) 000-0000.
Place of work
Emergency Contacts
Minimum two contacts, other than parents, to contact in case of emergency/authorized to pick up child.
1. Name
*
Relationship to child
Home Phone
*
Format: (000) 000-0000.
Cell or Work Phone
Format: (000) 000-0000.
2. Name
*
Relationship to child
Home Phone
*
Format: (000) 000-0000.
Cell or Work Phone
Format: (000) 000-0000.
Other Person(s) authorized to pick up child:
Name
*
Relationship
*
Phone
*
Name
Relationship
Phone
Name
Relationship
Phone
Child's Health Information and History
Health Plan
Group#
ID#
Child's Doctor
Phone
Format: (000) 000-0000.
Are your child's immunizations up to date?
Yes
No
Note: Attach a copy of immunization record. If not up to date, please explain
Does child have any known health problems?
Yes (If yes attach documentation)
No
Does your child get colds/flu often?
Does your child have any special needs or a family service plan?
Please list any serious prior injuries:
Check any of the following illnesses the child has had:
Influenza
Rheumatic Fever
Asthma
Earaches
Eczema
Croup
Diphtheria
Mumps
Pneumonia
Convulsions
Tonsillitis
Mumps
Polio
Measles
Whooping Cough
Chicken Pox
Bronchitis
Frequent Colds
Does your child have any known allergies?
Yes
No
If yes, what are they and what are your child's reactions:
Does your child take any medication on a regular basis?
Yes
No
If yes please list the name of the medication(s) and medical condition for which it is taken:
Does your child have any speech, hearing or visual problems?
Yes
No
Has your child ever been tested for the above?
Yes
No
Please comment on any other medical information/or special need the child care provider should be aware of:
Medication and Emergency Care Authorization
I authorize use of typical first aid supplies including but not limited to Neosporin, anti-bacterial spray, cortisone, sunburn treatments, band-aids, and liquid band-aids.
*
Yes
No
I authorize use of preventative supplies, such as sun block, bug repellant, hand lotion, diaper rash cream, etc
*
Yes
No
I authorize LifeKids MDO to obtain necessary: EMS and/or Ambulance transport in the event of an emergency. (Ambulance fees and/or healthcare costs are the responsibility of the parent/guardian
*
Yes
No
Comments/Exceptions
Additional information, notes or agreements made between this program and parents or guardians
(Date)
*
/
Month
/
Day
Year
Date
(Signature of parent/guardian)
*
(Date)
*
/
Month
/
Day
Year
Date
(Signature of parent/guardian)
*
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