Bridge Kidz Academy Enrollment Form

CHILD CARE ENROLLMENT FORM FOR LICENSE-EXEMPT FACILITIES
FACILITY/PROVIDER NAME
CHILD'S NAME*
GENDER*
M / F
BIRTHDATE*

MonthDayYear
Date
ADDRESS (STREET, CITY, STATE, ZIP CODE)*
IDENTIFYING INFORMATION
MOTHER'S / GUARDIAN'S NAME*
HOME PHONE NUMBER*
ADDRESS (STREET, CITY, STATE, ZIP CODE)*
CELL PHONE NUMBER*
E MAIL ADDRESS*
example@example.com
EMPLOYER OR SCHOOL ATTEND*
WORK/SCHOOL SCHEDULE*
EMPLOYER/SCHOOL ADDRESS (STREET, CITY, STATE, ZIP CODE)*
WORK TELEPHONE NUMBER*
FATHER'S / GUARDIAN'S NAME*
HOME TELEPHONE NUMBER*
ADDRESS (STREET, CITY, STATE, ZIP CODE)*
CELL TELEPHONE NUMBER*
E MAIL ADDRESS*
example@example.com
EMPLOYER OR SCHOOL ATTEND*
WORK/SCHOOL SCHEDULE*
EMPLOYER/SCHOOL ADDRESS (STREET, CITY, STATE ZIP CODE)*
WORK TELEPHONE NUMBER*
EMERGENCY CONTACT AND PERSONS AUTHORIZED TO TAKE CHILD FROM FACILITY

(OTHER THAN PARENT) AT LEAST ONE EMERGENCY CONTACT IS REQUIRED.
NAME*
RELATIONSHIP TO CHILD*
TELEPHONE NUMBERS (CELL. WORK HOME)*
ADDRESS (STREET CITY, STATE ZIP CODE)*
NAME*
RELATIONSHIP TO CHILD*
TELEPHONE NUMBERS (CELL. WORK HOME)*
ADDRESS (STREET CITY, STATE ZIP CODE)*
AUTHORIZATION FOR EMERGENCY MEDICAL CARE

I understand that I will be notified at once in case of an emergency with my child, and I will make arrangements for medical care of my child with the physician or hospital of my choice. If you cannot be reached to make necessary arrangements, or in a critical emergency requiring medical care, I authorize BRIDGE KIDZ ACADEMY to contact the following...
PHYSICIAN OR CLINIC
NAME*
TELEPHONE NUMBER*
PREFERRED HOSPITAL
NAME*
TELEPHONE NUMBER*

ACKNOWLEDGEMENTS
A. I HAVE BEEN INFORMED OF THE REQUIRED HEALTH AND SAFETY INSPECTIONS AND THE INSPECTION FORMS ARE AVAILABLE FOR REVIEW.
PARENT/GUARDIAN INITIALS*
B. WHEN MY CHILD IS ILL. I UNDERSTAND AND AGREE THAT S/HE MAY NOT BE ACCEPTED FOR CARE OR REMAIN IN CARE.
PARENT/GUARDIAN INITIALS*
C.*

I DO give permission for field trips/excursions. I understand I will be notified in advance when they are planned.I DO NOT give permission for field trips/excursions. I understand I will be notified in advance when they are planned.
PARENT/GUARDIAN INITIALS*
D.*

I DO give permission for the facility to transport my child.I DO NOT give permission for the facility to transport my child.
PARENT/GUARDIAN INITIALS*
E. I HAVE BEEN NOTIFIED THAT I MAY REQUEST NOTICE AT INITIAL ENROLLMENT OR ANY TIME THERE AFTER WHETHER THERE ARE CHILDREN CURRENTLY ENROLLED IN OR ATTENDING THE FACILITY FOR WHOM AN IMMUNIZATION EXEMPTION HAS BEEN FILED.
PARENT/GUARDIAN INITIALS*
HEALTH REPORT FOR SCHOOL-AGE CHILD, CHILD'S HEALTH HISTORY AND CURRENT HEALTH PROBLEMS
Type a question*

MY CHILD IS IN GOOD HEALTH IS ABLE TO PARTICIPATE IN GROUP CARE, HAS NO SPECIAL HEALTH OR MEDICAL REQUIREMENTS.MY CHILD IS ABLE TO PARTICIPATE IN GROUP CARE BUT HAS SPECIAL HEALTH OR MEDICAL REQUIREMENTS AS LISTED BELOW.
ANY ALLERGIES, SPECIAL MEDICAL CONDITIONS INCLUDING CHRONIC HEALTH PROBLEMS*
ANY SPECIAL MEDICATIONS AND/ OR RESTRICTIONS*
Parent/Guardian Signature*

Clear
DATE*

MonthDayYear
Date
Should be Empty:

CHILD CARE ENROLLMENT FORM FOR LICENSE-EXEMPT FACILITIES

IDENTIFYING INFORMATION

EMERGENCY CONTACT AND PERSONS AUTHORIZED TO TAKE CHILD FROM FACILITY

AUTHORIZATION FOR EMERGENCY MEDICAL CARE

PHYSICIAN OR CLINIC

PREFERRED HOSPITAL