Milestones Child Development Center Registration Form

Registration Form

Fill out the form carefully for registration
Program selection
Emergency Information
Today’s Date

MonthDayYear
Date
Child’s Name

First NameLast Name
Birth Date

MonthDayYear
Date
Parent #1

First NameLast Name
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Parent #2

First NameLast Name
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Parent #1 Email
example@example.com
Parent#2 Email
example@example.com
Allergies or Intolerance to Feed, Medication, etc.
Action to be taken in case of an emergency
Chronic physical or development difficulties/Illness
Child’s Physician
Physician Phone Number
Please enter a valid phone number.
Authorized pick up #1

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Authorized pick up#2

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Student Information
Student Name

First NameMiddle NameLast Name
Name child prefers to be called:
Age:
Birth Date

MonthDayYear
Gender
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please list the names of school/daycare centers previously attended:
If your child will be attending Milestones and another school/ program, please give the name of the other school/program and grade:
Parent # 1

First NameLast Name
Cell Phone Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Place Employed
Work Phone Number
Please enter a valid phone number.
Email
example@example.com
Address ( if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent #2

First NameLast Name
Cell Phone Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Place Employed
Work Phone Number
Please enter a valid phone number.
Email
example@example.com
Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Person(s) or Agency having legal custody of child if other than parent listed above

First NameLast Name
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Email
example@example.com
Why My Child Is Special
Previously, my child was cared for:

At homeAt another centerAt an in home day cares
His or her day was :
How many other children was your child around on a daily basis?
Is your child potty trained?
What indication does he or she give when requesting to use the toilet ?
Does your child require help in:

Dressing/ undressingEatingWashing hands
Does your child have any special fears or problems?
If yes, please explain:
Does your child take naps?

NoYes
How many naps do they take a day?
Does your child have special dietary needs or allergies?
If yes, please explain
Special hint/concerns regarding mealtime:
Favorite games/songs/books
My child enjoys the following activities:
My child can’t part with (I.e. toy, stuffed animals)
Siblings names and ages:
Does your child have any other friends/acquaintances at Milestones Child Development center ?
If yes, who are they ?
I would describe my child as :
Additional information that would help us best meet you and your child’s needs ?
Sick Policy
Sick Policy

I understand as per Virginia licensing standards, we are required by law to notify you in writing of any illnesses that require you to pick up your child, and required to do so, in a timely manner.I understand that the state of Virginia requires us to let you: if your child’s temperature reaches 100°, has persistent diarrhea, has persistent, vomiting, and any transmissible disease that falls under the Virginia Department of health’s disease chart.I understand in the event of any of these occurrences, my child may not return until after 24 hours symptom free and medication free to ensure the healthiness of our students and staff
Medical Agreement
Medical Agreement

I/We permit, Milestones child development center to acquire immediate medical care if any emergency occurs when the parent/guardian’s cannot be located immediately.I/We agreed to inform Milestones child development center within 24 hours of the next business day after his/her child, or any member of the household has inquired and reportable, transmissible disease, as defined by the state board of health, excluding life-threatening diseases must be reported immediately.I understand Milestones Child Development Center agrees to notify parent/guardian is when the child becomes ill and parent/guardian must arrange to have the child picked up as soon as possible if a question about the center.I/We authorizes Milestone Child Development Center to obtain immediate medical care and consents to the hospitalization of, the performance of necessary diagnosis test upon, the use of surgery on, and/or the administration of drugs immediately. It is also understood that this agreement covers only those situations which are true emergencies, and only when he/she cannot be reach otherwise he/she expects to be notified immediately.I/We will be responsible for the payment of medical care expenses.
Does your child have Medical Insurance?
Name of Medical Insurance
Policy Number
Insured Parent’s Name

First NameLast Name
Authorization For Emergency And First Aid
I hereby give the staff and Director represent in Milestones Child Development Center permission for any and all necessary emergency medical and First Aid care for my child First Name Last Name ,while my child is in Milestones Child Development in Center custody.
Photo Permission
Photo Permission
Program Information
Program information acknowledgment

I understand the staff will attempt to notify me whenever my child becomes ill, has behavior issues, or is in the situation of emergency, or inclement weather. I will arrange to have my child picked up within one hour of notification.If my child or someone in my household comes down with a reportable communicable disease, I/we would notify staff with a 24 hour so they can notify the parents of other students in the local health department when necessary(our names will remain confidential)I understand that in emergency operation plan has been developed to help staff and participates be prepared for situations. This is posting it all classroom and is updated each fall. A copy of the plan is available upon request.I/We will provide my child proof of identity original birth certificate, passport, hospital records, physical, and immunization records, an emergency form by my child’s first day of attendance. I understand my child will not be allowed to attend until all information is on file.I/We agreed to review the contents of the parent handbook that was emailed to me and will comply with all its contents.I/We understand that the termination/withdrawal policy requires a two week credit notice. A proper notice is not provided. I will be responsible for the tuition fee.I understand a Milestones Child development center will be open for Day program Monday through Friday from 6:45 AM to 6 PM and for the Night program 6pm to 6am for children ages six weeks to 12 years old with the exception of federal holidays and others stated days as per the Milestones calendar.I agree to pay a nonrefundable registration fee at the time of enrollment to be renewed each August. I understand my weekly tuition is based on enrollment throughout the school year and will not be reduced or prorated based on absences or school closures.I agree to pay in advance each week’s tuition on Friday. I am aware there a $10 bookkeeping fee will be charged for payments received after Friday.I am aware that a late pick up fee will occur if late and equals $20for the day program and $50 for night per 10 minutes per child or any part thereI/We hear by certify that all information noted above is correct, and true. I/we understand the financial commitment involved in enrollment at Milestones Child Development Center. In addition, I/we agreed to meet the financial commitment to Milestones Child Development center and to abide by the policies and procedures set forth in the parent handbook.
Please sign here:

Powered by Jotform SignClear
Should be Empty:

Registration Form

Emergency Information

Student Information

Why My Child Is Special

Sick Policy

Medical Agreement

Authorization For Emergency And First Aid

Photo Permission

Program Information