Prime Time Registration Form Non School Days

Prime Time Extended Learning Center, LLC

Registration Form Non School Days
Childs name*
Birth Date*

MonthDayYear
Date
Grade*
Address*

Street Address

Street Address Line 2

CityState / Province

Zip Code
Childs parent guardian name*
Home Phone*
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
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*
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
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*
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Relationship*
Address*
Name
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Relationship
Address
Name
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Relationship
Address
Other than you, who else has permission to pick up your child?
Name*
Home Phone*
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Address*
Name
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Address
Name
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Address
Who DOES NOT have permission to pick up your child?
Name
Reason
Name
Reason
Child's Health Information:
Child's Health Care Provider*
Health Care Providers Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date of child's last physical exam*

MonthDayYear
Date
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
Format: (000) 000-0000.
Date of childs last physical exam

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

YesNo
Please specify the date(s) you are registering for*
Care for Non-school days must be paid at the time of enrolling. Once signed up, there is no refund for no-shows or cancellations. Please send your payment via Venmo to @primetime-tacoma, code 9020 or mail acheck or money order to Prime Time at 1911 N. Mullen St., Tacoma 98406.Non-school days do not include lunch. Parents must provide a home lunch during Non-school days.
Will State Subsidy be paying for your childcare?*

YesNo
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 TimeExtended Learning Center staff to give and or seek medical attention and I authorize any and allhospitalization, medical, dental and/or surgical treatment deemed advisable by the circumstances. I waivemy right of informed consent to such treatment. I also give my permission for my child to be transported byambulance for treatment. I understand that any of the foregoing care will be at my expense. I certify underpenalty of perjury under the laws of the State of Washington that this information is true and correct. Iunderstand any of the foregoing care will be at my expense.
Parent guardian signature*
Date*

MonthDayYear
Date
Parent guardian signature*
Date*

MonthDayYear
Date
Should be Empty:

Prime Time Extended Learning Center, LLC