Registration Form

Prime Time ELCRegistration Form
Child's name*
Age*
Birthday*

MonthDayYear
Cell phone*
Email address*
example@example.com
Grade*
Teacher's Name (leave blank if unknown)
Parent's mailing address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
In case of emergency, please list phone numbers where parents/guardians can be reached while your child is at Prime Time.
Name*
Relationship*
Phone*
Second Phone
Name*
Relationship*
Phone*
Second Phone
Individuals picking your child up must be authorized in writing. Phone calls will not work in accordance with State law. Please list individuals authorized to pick-up your child, including yourself.
Name (parent)*
Relationship*
Phone*
Name (parent)*
Relationship*
Phone*
Name
Relationship
Phone
Name
Relationship
Phone
Medical Information

Check if you do not have a preferred doctor/hospital.
Dr
Hospital
Hospital Phone
Health insurance*
Policy number*
Date of last exam*

MonthDayYear
Date
Date of last tetanus shot (DPT)*

MonthDayYear
Date
Dentist Name*
Date of last Dental exam*

MonthDayYear
Date
Does your child have any drug allergies?*
If yes: Please List them
Does your child have any specific health problems or food allergies?*
Is your child currently under a doctor's care, or taking any medications?*
Are there any specific fears, likes or dislikes that will help us care for your child?*
How does your child act when ill?
Any additional information that will help us better care for your child:
Please select which site you are registering for:*

Browns PointCrescent HeightsLowellNE Tacoma
Please select the care option your child will be using:*

Full-time $550AM $325 (3-5 days morning only)PM $350 (3-5 days afternoon only)
Prime Time has permission to photograph/video my child/family and use material in print and electronically for promotional material and training purposes:*

YesNo
Prime Time has my permission to walk my child to and from school and on walking field trips to local parks and attractions:*

YesNo
I authorize Prime Time to provide care for my child. In the event my child is injured or becomes seriously ill, and I cannot be reached, I authorize the Prime Time staff to seek medical attention and I authorize any and all hospitalization, medical, dental and/or surgical treatment deemed advisable by the circumstances. I understand any of the foregoing care will be at my expense.
Signature of Parent/Legal Guardian*

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Date*

MonthDayYear
Date
Signature of Parent/Legal Guardian*

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Date*

MonthDayYear
Date
Please include a deposit, check or money order, when registering your child. $50 per child/$100 maximum per family. Your deposit will be credited towards your September tuition payment.
Should be Empty:

Prime Time ELCRegistration Form