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 Director.*

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*
which site you are registering for:*

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

Full-time $575 (3-5 days)AM $350 (3-5 days morning only)PM $375 (afternoons only)
Will State Subsidy be paying for your childcare?*

YesNo
Prime Time has my permission to take my child on walking field trips to Norpoint Center or neighborhood parks.*

YesNo
When would you like your child to start attending Prime Time?*
Are you eligible for a TPS or Military 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
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Prime Time Extended Learning Center, LLC