Hanover St

CHILD CARE REGISTRATION AND EMERGENCY INFORMATION

In this section you will complete all required enrollment forms. If you have any questions, please email Kafré O'Connell at operations@uvims.com.
Name of the child*

First Name Last Name
Date of birth of the child*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

IDENTIFYING INFORMATION OF PARENT/S OR GUARDIAN/S LEGALLY RESPONSIBLE FOR CHILD:

In this section you will complete all required enrollment forms. If you have any questions, please email Kafré O'Connell at operations@uvims.com.
Name of Parent/Guardian #1*

First NameLast Name
Address of Parent/Guardian #1*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian #1 Phone Number*
Please enter a valid phone number.
Email Parent/Guardian #1*
example@example.com
Indicate where parent/guardian above can be reached while child is in care. Include name, address and phone number of business if applicable. Include any special instructions, e.g. pager, cell phone, etc.
Business Name Parent/Guardian #1:
Business Address Parent/Guardian #1

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone Number Parent/Guardian #1
Please enter a valid phone number.
Business Hours Parent/Guardian #1
Special instructions for reaching out to Parent/Guardian #1.
Name of Parent/Guardian #2

First NameLast Name
Address of Parent/Guardian #2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number Parent/Guardian #2
Please enter a valid phone number.
Indicate where parent/guardian above can be reached while child is in care. Include name, address and phone number of business if applicable. Include any special instructions, e.g. pager, cell phone, etc.
Business Name Parent/Guardian #2:
Business Address Parent/Guardian #2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone Number Parent/Guardian #2
Please enter a valid phone number.
Business Hours Parent/Guardian #2
Email Parent/Guardian #2
example@example.com
Special instructions for reaching out to Parent/Guardian #2.

Emergency Contact Person

You (parent/guardian) are required to list at least 1 person with whom you would feel comfortable leaving your child, and who could assume responsibility for your child if you could not be reached immediately in an emergency, or if for some reason you could not pick up your child and were unable to communicate with the program. Examples: if your child were sick and you were not accessible, or if you experienced sudden illness between work and picking up your child.
Name Emergency Contact #1*

First NameLast Name
Relationship Emergency Contact #1*
Address Emergency Contact #1*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number Emergency Contact #1*
Please enter a valid phone number.
Name Emergency Contact #2

First NameLast Name
Relationship Emergency Contact #2
Address Emergency Contact #2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number Emergency Contact #2
Please enter a valid phone number.
NON-EMERGENCY ALTERNATE PICK-UP PERSON/S:
Name Alternate Contact #1*

First NameLast Name
Relationship Alternate Contact #1*
Address Alternate Contact #1*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number Alternate Contact #1*
Please enter a valid phone number.
Name Alternate Contact #2

First NameLast Name
Relationship Alternate Contact #2
Address Alternate Contact #2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number Alternate Contact #2
Please enter a valid phone number.

NOTE TO PARENT/S or GUARDIAN/S

The licensing authority for this program is the bureau of licensing and certification, child care licensing unit. Child care programs are required to post a copy of the statement of findings and corrective action plan for the most recent visit in a location which is accessible to parents, and must maintain copies of the statement of findings and corrective action plan for the preceding visit and make them available for parents to review upon request. Statements of findings and corrective action plans are also available on-line at https://nhlicenses.nh.gov/verification/Search.aspx?facility='Y or by calling the unit at 603-271-9025 or 1-800-852- 3345, extension 9025.During visits to programs, licensing staff speak with children regarding the care they receive at the program if in the judgment of the licensing staff the children's response would be valuable in determining compliance with licensing rules. Licensing staff are experienced in working with children and trained to speak with children in a manner that is respectful and non-leading. Children will remain with their class or group during these conversations with licensing staff, and at no time will a child be forced to speak with a licensing coordinator. Please indicate whether licensing staff may speak with your child while they are with their class or group:
I give permission for child care licensing staff to speak with my child while with their class or group.I do not give my permission for child care licensing staff to speak with my child while with their class or group.
I give permission for child care licensing staff to interview my child at the child care program separate from their class or group.I wish to be notified prior to child care licensing staff interviewing my child at the child care program separate from their class or group.I do not give permission for child care licensing staff to interview my child at the child care program separate from their class or group.

MEDICAL INFORMATION
Any chronic conditions, allergies or medications that could be important in case of sudden illness or injury:*
Child's usual physician:*
Physician's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician's Phone Number*
Please enter a valid phone number.

EMERGENCY MEDICAL TREATMENT AUTHORIZATION

I hereby give permission for the staff of __IMMERSION MONTESSORI SCHOOL__ to provide simple first aid treatment to my child when necessary. In the event of a more serious illness or injury, I give permission for my child to be transported to a hospital or other emergency medical facility to receive emergency medical treatment. I also authorize ambulance/rescue squad attendants to administer such treatment as is medically necessary, and I authorize licensed health practitioners working in the hospital or emergency medical facility to examine and provide emergency medical treatment to my child if warranted. I understand that I will be contacted by child care program personnel as soon as possible regarding any emergency involving my child.
Sign Here

IMS
Are you a current or former IMS Staff member?*

YesNo
Are you an immediate family member of a current or past IMS student?*

YesNo

Review Orientation Documents
Click here

Upload your subsidy documents (if applicable).

Cancelof

The Brightwheel App

Complete these steps to get set up and learn how to use the Brightwheel App, which is a school management software used by IMS families for the following: Daily communication with center staff (director, guides, assistant guides, etc., Receive notifications about snow days, closures, and other time sensitive alerts, Checking in and checking out students daily, Getting updates about our daily activities).
Getting Started - Review the following videos for basic information on how to use Brightwheel. If you do not already have access to Brightwheel, please call Kafré O'Connell at 603-322-3556 for assistance.
Set up Notifications

Please ensure that you have downloaded the app and have allowed for push notifications to be sent to your phone. This will allow for you to receive instant alerts, updates, and messages about your child.

Deposit to secure the spot

This deposit will be applied towards the first monthly payment.

Should be Empty:

Account Details
Bank Account Type
Routing Number	Account Number
Name On Account	Bank Name

CHILD CARE REGISTRATION AND EMERGENCY INFORMATION

IDENTIFYING INFORMATION OF PARENT/S OR GUARDIAN/S LEGALLY RESPONSIBLE FOR CHILD:

Indicate where parent/guardian above can be reached while child is in care. Include name, address and phone number of business if applicable. Include any special instructions, e.g. pager, cell phone, etc.

Indicate where parent/guardian above can be reached while child is in care. Include name, address and phone number of business if applicable. Include any special instructions, e.g. pager, cell phone, etc.

Emergency Contact Person

NON-EMERGENCY ALTERNATE PICK-UP PERSON/S:

NOTE TO PARENT/S or GUARDIAN/S

MEDICAL INFORMATION

EMERGENCY MEDICAL TREATMENT AUTHORIZATION

IMS

Review Orientation Documents

Complete the Enrollment Process

Upload Required Documents

The Brightwheel App

Set up Notifications

Deposit to secure the spot