BabyVillage NE Portland | Enrollment Form

Portland Enrollment Registration Form

Child Information. One Child Per Form.
Location*
Please select your program*
Start Date*

MonthDayYear
Date
End Date

MonthDayYear
Date
Name of Child (First, Middle Initial, Last):*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Child’s Primary Language: Type a question*
Parent/Guardian’s Primary Language:*
Home Email Address:*
example@example.com
Home Phone:*

Area CodePhone Number
Child’s Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SingleMarriedDivorcedSeperatedWidowed
MotherFatherBoth ParentsGuardian
List the family members your child lives with—include names and ages of siblings:
YesNo
If yes, please list:
YesNo
Immunization Records

Browse Files

Cancelof
Parent's Information

Guardian(s) of the child(ren)
Parent's Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Employer*
Employer Work Hours*
Work Email:*
example@example.com
Emergency Contact Information

Person other than parent/guardian who is authorized to pick up child
Please list the persons you would like contacted (in order of priority) if you cannot be reached in case of emergency. We will not release a child to anyone (other than the parent) under the age of eighteen (18), including siblings. Additionally, please list the persons you would like to be authorized for pick-up only on a given day (i.e., babysitter). For the safety of your child, we will request all authorized release persons with whom staff are not familiar to provide government-issued photo identification at the time of pick-up. You may also be required to complete state specific emergency release forms required by individual state child care licensing regulations.
Emergency Contact Information

Person other than parent/guardian who is authorized to pick up child
Emergency Contact (1) Name:*

First NameLast Name
Emergency Contact (1) Relationship:*
Emergency Contact (1) Phone Number*

Area CodePhone Number
Emergency Contact (2) Name:*

First NameLast Name
Emergency Contact (2) Relationship:*
Emergency Contact (2) Phone Number*

Area CodePhone Number
Parent or Guardian Authorization

By signing below, you give WeVillage permission for the following:
- My child may be taken on field trips or excursions by bus or streetcar, as well as on neighborhood walks under required supervision.
- My child may participate in water play at local parks.
- My child may be given non-prescribed medication as indicated on the container. This may include sunscreen, antibacterial first aid cream, and diapering ointment. Prescription medications must be current and a permission slip is required for each medication.
- In an emergency, the childcare facility has my permission to call an ambulance, or take my child to any available physician or hospital at my expense to obtain medical treatment. In most emergencies, 911 is called and the child is transported to the nearest hospital and treated by the on-call physician. The parent or guardian of the child is notified as soon as possible.
If your child needs emergency medical care and you aren’t available to give formal consent to medical authorities, care may be unnecessarily delayed. All children under the care of WeVillage must have a completed Emergency Consent Form on file; in the event of a medical emergency, this form will accompany your child to the hospital.

I/we hereby authorize WeVillage to give consent for all medical and/or surgical treatment that may be required for our child/children during our absence.
Parent/Guardian Signature*
Child's Medical History
YesNo
If yes, please explain
List any allergies, or type "N/A" if none.*
List any medications, or type "N/A" if none.*
Date of last tetanus shot*

MonthDayYear
Date
Doctor & Dental Information
Physician:*
Physician Telephone:*

Area CodePhone Number
Health Insurance Co.:
Member/Group No.:
Policy Holder Name:
Policy Holder DOB:
Dentist:*
Dentist Telephone:*

Area CodePhone Number
Dental Insurance Co.:
Dental Member/Group No.:
Dental Policy Holder Name:
Dental Policy Holder DOB:
Family Handbook Acknowledgement Form

Dear Families, It is important that you are aware of our center’s policies, some of which are regulations pursuant to our license with the Oregon Early Learning Division. Please read and familiarize yourself with the policies found in the Family Handbook and use them as a reference in cases such as illness, schedule, meals, and other day-to-day items you might have questions about. Read Full Policy Page here: www.wevillage.com/rules-and-policies-portland
Acknowledgment: I acknowledge that I have read and am familiar with babyvillage policies and regulations set forth in the Family Handbook.*
Enrollment Agreement

Please Initial each statement and sign at the bottom.
Monthly tuition is due via ACH electronic check*
Bank Name:*
Exact Name on Bank Account*

First NameLast Name
Routing Number:*
Account Number:*
Tuition Rate
Deposit Date*

MonthDayYear
Date
Monthly tuition is due via ACH electronic check*
Infant CareToddler CareFlexible Childcare
I understand there is a $250 Refundable Deposit (not applicable to Flex Care)*
I understand there is a $275 Enrollment Fee*
I authorize WeVillage to store my CC on filefor fees associated with my care.*
Please check all the following and then sign at the bottom. *
Parent’s signature:*
Date:*

MonthDayYear
Date
Director’s signature
Should be Empty:

Portland Enrollment Registration Form

Parent's Information

Emergency Contact Information

Emergency Contact Information

Parent or Guardian Authorization

Child's Medical History

Family Handbook Acknowledgement Form

Enrollment Agreement