Prime Time NEW Registration Form

Prime Time Extended Learning Center, LLC

Registration Form
Childs name*
Birth Date*

MonthDayYear
Date
Grade*
Address*

Street Address

Street Address Line 2

CityState / Province

Zip Code
Childs parent/guardian name*
Home Phone*
Work Phone
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Zip Code
Address

Address where you can be reached while child is in care

Street Address Line 2

CityState / Province

Zip Code
Childs parent/guardian name*
Home Phone*
Work Phone*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Zip code
Address

Address where you can be reached while child is in care

Street Address Line 2

CityState / Province

Zip Code
Other People to Notify in Case of Emergency! Please include one emergency contact that is not a parent or guardian.
Name*
Home Phone*
Work Phone
Relationship*
Address*
Name
Home Phone
Work Phone
Relationship
Address
Name
Home Phone
Work Phone
Relationship
Address
Other than you, who else has permission to pick up your child?
Name*
Home Phone*
Work Phone
Address*
Name
Home Phone
Work Phone
Please enter a valid phone number.
Address
Name
Home Phone
Work Phone
Please enter a valid phone number.
Address
Who DOES NOT have permission to pick up your child?
Name
Reason
Name
Reason
Emergency medical or dental plan if child does not have provider
Child's Heath Care Provider:
Name
Phone Number
Please enter a valid phone number.
Special Health Problems: Is this a concern Prime Time needs to be aware of? If yes, please complete the Individual Care Plan and meet with your Site*

YesNo
Allergies, including drug reactions: Is this a concern Prime Time needs to be aware of? If yes, please complete the Individual Care Plan and meet with your Site Director.*

YesNo
Regular Medications
Childs Dentist
Phone Number
Date of childs last physical exam

MonthDayYear
Date
Child's Medical Insurance Coverage
Health Insurance
Policy Number
Is Child Native American?*

YesNo
which site you are registering for:*

Browns PointCrescent HeightsLowellNE Tacoma
Which care option your child will be using:*

Full-time $550 (3-5 days)AM $325 (3-5 days morning only)PM $350 (afternoons only)
Will State Subsidy be paying for your childcare?*

YesNo
Are you eligible for a discount?*

YesNo
If so, which one?
Consent to Medical Care and Treatment of Minor Children

In the event my child is injured or becomes seriously ill and I cannot be reached, I authorize Prime Time Extended Learning Center staff to give and or seek medical attention and I authorize any and all hospitalization, medical, dental and/or surgical treatment deemed advisable by the circumstances. I waive my right of informed consent to such treatment. I also give my permission for my child to be transported by ambulance for treatment. I understand that any of the foregoing care will be at my expense. I certify under penalty of perjury under the laws of the State of Washington that this information is true and correct. I understand any of the foregoing care will be at my expense.
Parent/guardian signature*

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Date*

MonthDayYear
Date
Parentguardian signature*

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Date*

MonthDayYear
Date
Should be Empty:

Prime Time Extended Learning Center, LLC