Blessed Baby Registration-Form

Blessed Baby Registration Form

Childs name*

Age*

Birthday*

Cell phone*

Email address*

example@example.com

Grade*

Teacher's Name (leave blank if unknown)

Parents mailing address*

City*

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*

Phone

Name*

Relationship*

Phone*

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*

Relationship*

Phone*

Name*

Relationship*

Phone*

Name

Relationship

Phone

Name

Relationship

Phone

Medical Information

Dr

Hospital

Phone

Check if you do not have a preferred doctor/hospital

Health insurance*

Policy number*

Date of last exam*

Date

Date of last tetanus shot (DPT)*

Date

Dentist Name

Date of last Dental exam

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 Doctors 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 circle the care option your child will be using:*

Full-timePart-time

Blessed Baby has permission to photograph/video my child/family and use material in print and electronically for promotional material and training purposes:*

YesNo

Blessed Baby has my permission to walk my child to and from school and on walking field trips to local parks and attractions:*

YesNo

I authorize Blessed Baby 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 Blessed Baby 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 ParentLegal Guardian*

Date*

Date

Signature of ParentLegal Guardian*

Date*

Date

Please include a check or money order for the registration fee when registering your child: $50 per child/$100 maximum per family. Additionally, with a two-week deposit, your deposit will be credited towards your last month's tuition payment.