Kiddie Land Learning Center

Enrollment Form
Child's Name*
Date of Birth*

MonthDayYear
Date
Home Address*
Date of Enrollment*

MonthDayYear
Date
Mother's Name*
Cell Phone*
Please enter a valid phone number.
Home Address*
Email*
example@example.com
Father's Name*
Cell Phone*
Please enter a valid phone number.
Home Address*
Email*
example@example.com
Mother's Work*
Business Phone*
Please enter a valid phone number.
Business Address*
Father's Work*
Business Phone*
Please enter a valid phone number.
Business Address*
Emergency Contact 1*
Phone Number*
Please enter a valid phone number.
Relationship to Child*
Home Address*
Emergency Contact 2*
Phone Number*
Please enter a valid phone number.
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
Date
Child's Doctor*
Telephone Number*
Please enter a valid phone number.
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.

Powered by Jotform SignClear
Are there any medical conditions that our staff needs to be aware of?*

YesNo
Comments
Does your child have any food allergies?*

YesNo
Medication(s) Child is Taking
Does your child have any allergies to medicine*

YesNo
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*

Powered by Jotform SignClear
Date of Signature*

MonthDayYear
Date

Parent
Receipt of Information*

Information to Parents DocumentPolicy of the Release of ChildrenPolicy on Communicable Disease ManagementExpulsion PolicyPolicy on the Use of Technology and Social MediaTuition Agreement
Child's Name*
Parent Name*
Parent's Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Should be Empty:

Enrollment Form

Medical

Policies

Tuition Agreement

Parent