Daycare

Daycare
CHILD INFORMATION:
Childs Name
Nickname
Date of Birth

MonthDayYear
Date
Gender
Shining Star Development Learning Center
Date of Admission

MonthDayYear
Date
Age at Admission
Address

Address

Street Address Line 2

CityState / Province

Zip Code
City
State
Primary Language of Child
Primary Language of Parents
PARENT(S)/GUARDIAN(S) DETAILS:
ParentGuardian
ParentGuardian
Where
Where
Phone No
Format: (000) 000-0000.
Phone No
Format: (000) 000-0000.
EMERGENCY CONTACT INFORMATION:
In the event of an emergency when I may not be reached, the Educator may contact the following individuals whom I authorize to take my child from the child care premises.
Name
Name
Relationship to Child
Relationship to Child
Phone Number
Format: (000) 000-0000.
Phone Number
Format: (000) 000-0000.
AUTHORIZED PERSONS FOR PICK-UP:
Name of Person 1
Name of Person 2
Relationship
Relationship
Phone Number
Format: (000) 000-0000.
Phone Number
Format: (000) 000-0000.
Childs Physician
Physician's Phone Number
Format: (000) 000-0000.
Allergies or Medical Conditions
Medications if any
Date of Last Tetanus Shot

MonthDayYear
Date
authorize the staff of Shining Star Development Learning Center to call a medical practitioner or ambulance in the case of accident or illness of my child, if the parents cannot be reached immediately.
ANTICIPATED DAYS/TIME OF ATTENDANCE:

DayArrival Time Departure Time
Monday
Thursday
Tuesday
Friday
Wednesday
Saturday
Is the child potty trained? [] Yes [ ] No

Any concerns regarding your child's development (behaviour, speech, language,
Any concerns regarding your childs development behaviour speech language mobility etc please list and describe
mobility, etc) (please list and describe):

Other health care professionals involved in your child's life (Occupational Therapist/Physical Treatment, etc) :
Has your child had previous Daycare experiences If yes how did heshe adapt
What isare your childs favorite toysactivities
How does your child behave around other children
Any Other Comments
I, the undersigned, hereby acknowledge that I have provided accurate information on this registration form, and I have read and understood the policies and procedures of

.I agree to comply with the terms and conditions outlined by the

Documenting the Centre's activities is a part of our program. From time to time your child's picture may be taken. I grant permission for the daycare to take photographs of my child for educational and promotional purposes.
ParentGuardian Signature
Date

MonthDayYear
Date
Daycare Center Staff Signature
Should be Empty:

Daycare

CHILD INFORMATION:

Shining Star Development Learning Center

PARENT(S)/GUARDIAN(S) DETAILS:

EMERGENCY CONTACT INFORMATION:

AUTHORIZED PERSONS FOR PICK-UP: