GLSA Returning Student Registration

Emergency Contact Information
I give my permission for any of the following individuals to be contacted and my child may be released to any of them.*

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Parent/Guardian 2 Signature

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In the event of an emergency, if you are not able to contact me, contact the following:
Name 1*

First NameLast Name
Name 1 Phone Number*
Please enter a valid phone number.
Name 2*

First NameLast Name
Name 2 Phone Number*
Please enter a valid phone number.
Name 3

First NameLast Name
Name 3 Phone Number
Please enter a valid phone number.
These individuals also have permission to pick up my child:
Name 1*

First NameLast Name
Name 1 Phone Number*
Please enter a valid phone number.
Name 2*

First NameLast Name
Name 2 Phone Number*
Please enter a valid phone number.
Name 3

First NameLast Name
Name 3 Phone Number
Please enter a valid phone number.
Name 4

First NameLast Name
Name 4 Phone Number
Please enter a valid phone number.
Name 5

First NameLast Name
Name 5 Phone Number
Please enter a valid phone number.
Out of State Emergency Contact (for use in the event of a disaster, i.e. earthquake):*

First NameLast Name
Out of State Emergency Contact: Phone Number*
Please enter a valid phone number.
Out of State Emergency Contact: Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CIS Form & Instructions
Child's Certified CIS Vaccination Form *

Cancelof

Child's Health Information

DEL licensing requires us to have on file the name of your child’s physician and dentist. If your child does not have a physician or dentist please provide a written plan of action you would like us to follow for a dental or medical injury or emergency. Thank you.
Child's medical care provider or parent's/guardian's medical facility for treatment*

First NameLast Name
Child's medical care provider or parent's/guardian's medical facility for treatment phone number*
Please enter a valid phone number.
Child's medical care provider address or parent's/guardian's medical facility address for treatment*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of last physical exam (if available)*

MonthDayYear
Date
Child's dental care provider or parent's/guardian's dental facility for treatment*

First NameLast Name
Child's dental care provider address or parent's/guardian's dental facility address for treatment*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child's dental care provider or parent's/guardian's dental facility for treatment phone number*
Please enter a valid phone number.
Date of last dental exam (if available)*

MonthDayYear
Date
Known health conditions (An individual care plan from child's care provider is required for any food allergies or special dietary requirements due to a health conditions.)*
Parent/Guardian Signature*

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Date Signed*

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Date
Parent/Guardian Signature

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Consent to medical care and treatment of minor children
I give permission that my child, child's name* may be given first aid/emergency treatment by the child care licensee and or qualified staff at:

Green Lake School Age Care Program
6415 1st Ave NE
Seattle, WA 98115
Parent/guardian signature*

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Parent/guardian signature

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When I cannot be contacted, I authorize and consent to medical, surgical, and hospital care, treatment, and procedures to be performed for my child by a licensed physician, health care provider, hospital, or aid car attendant when deemed necessary or advisable by the physician or aid car attendant to safeguard my child’s health.

I waive my right of informed consent to such treatment.

I also give permission for my child to be transported by ambulance or aid car to an emergency center for treatment.

I certify under penalty of perjury under the laws of the State of Washington that this information is true and correct.
Parent/Guardian Signature*

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Parent/Guardian Signature

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PLEASE NOTE:

IF YOUR CHILD NEEDS TO HAVE MEDICATION ON HAND WHILE ATTENDING GLSA YOU MUST REQUEST Medical Authorizarion FORMS FROM GLSA.

ANY LIFE THREATENING ALLERGIES MUST BE DOCUMENTED ON THE REQUIRED FORMS AND NEEDED MEDICATION MUST BE PROVIDED ON SITE BEFORE STARTING AT GLSA.

Developmental, Social, and Health History

We want to provide your child with the best care possible, and be sensitive to any needs that they have. Please help us get to know your child thoroughly completing this section. Thank You!
What are some of your child’s favorite foods?*
Would you say that your child generally enjoys eating? *
Is your child on a special diet? (Please Note: State law requires a form signed by your child’s health care provider if your child has diet modifications)*
Does your child have food allergies? Please clarify, if yes. Severe, life-threatening food allergies require additional documentation. Please request the forms via email.*
Are there any foods that you do not want us to offer your child?*
Are there any foods special to your home or culture that you would like to share with our center so that we could make your child more comfortable here?*
Any known allergies to medication, insects, animals?*
Do you have any concerns about your child’s eating habits?*
Please provide any surgeries and past major illnesses your child has had.
Do you have any concerns about your child’s hearing or vision?*
Does your child use any assistive devices? (e.g. glasses, hearing aids, braces)*
Do you have any concerns about your child’s language development?*
Do you have any concerns about your child’s ability to move? If yes, please describe.*
What are your child’s favorite activities? Is there anything new they are interested in trying?*
What kinds of toys does your child like to play with?*
How would you describe your child’s temperament and personality? (ex. quiet, shy, moody, outgoing, competitive, cheerful, easygoing, intense, fiery, assertive, thoughtful, impulsive, altruistic etc.) *
Does your child enjoy playing with other children?*
Does your child enjoy playing alone?*
Does your child enjoy playing alone?*
Do you have any questions or concerns about your child’s social and emotional skills?*
What is the best way to comfort your child?*
Does your child fear certain things?*
How would you describe your child's growth this past year?*
What tools are you currently using to guide/teach your child appropriate behavior?*
How can we help ease your child’s adjustment to our program?*
Transitions, challenging life events and losses, such as separation, divorce, or death, can affect a child’s behavior. It helps us to be aware of significant changes in your child’s life, so we can understand and support them while at GLSA. Has anything happened that may affect your child’s behavior? If yes, please explain. *
We appreciate any information that may assist us in helping your child be happy, healthy, and comfortable while at GLSA. Please share anything else you feel would be helpful for GLSA to best support your child. Thank you.*
Parent/Guardian Signature*

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Parent/Guardian Signature

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GLSA Registration for Returning Students

Emergency Contact Information

Child's Health Information

Consent to medical care and treatment of minor children

Permission to Participate & Consent

GLSA Tuition Agreement

Developmental, Social, and Health History