Kiddie Land Learning Center

Enrollment Form
Child's Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Home Address
Date of Enrollment

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Mother's Name
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Address
Email
example@example.com
Father's Name
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Address
Email
example@example.com
Mother's Work
Business Phone
Please enter a valid phone number.Format: (000) 000-0000.
Business Address
Father's Work
Business Phone
Please enter a valid phone number.Format: (000) 000-0000.
Business Address
Emergency Contact 1
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Child
Home Address
Emergency Contact 2
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Child
Home Address
Name of person PROHIBITED from picking up the child:

Medical

PARENTAL AUTHORIZATION FOR EMERGENCY TREATMENT
Child's Name
Age
Date Of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child's Doctor
Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Child's Insurance Company/HMO
Group Number
Identification Number
I(we) state that we are the parent(s)/guardian(s) having legal custody of the above child and attest that the information above is correct. I (we) authorize the above childcare center director or director’s designee to obtain emergency treatment for my child. I consent to an X-RAY examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care to be rendered to the minor at a recognized medical facility, under the general or special supervision of a licensed physician or surgeon.
Are there any medical conditions that our staff needs to be aware of?
Comments
Does your child have any food allergies?
Medication(s) Child is Taking
Does your child have any allergies to medicine
Medication(s) Child is Taking
The following steps will be followed in an emergency:
1. The parent/guardian will be contacted immediately.
2. The child’s physician will be contacted.
3. We will attempt to contact you through all of the emergency persons listed on the child’s application form.
4. If we cannot contact you or your child’s physician, we will do any or all the following:
  1. Call for emergency first aid assistance/transportation
  2. Call another physician
  3. Have the child transported to an emergency hospital in the company of a staff member.
Parent Signature
Date of Signature

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Parent
Receipt of Information
Child's Name
Parent Name
Parent's Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Enrollment Form

Medical

Policies

Tuition Agreement

Parent