Enrollment Form
Use of form: Use of this form is mandatory for Family Child Care Centers to comply with DCF 250.04(6)(a)1. Failure to comply may result in issuance of a noncompliance statement. This form may also be used by Group Child Care Centers and Day Camps to comply with DCF 251.04(6)(a)1. and DCF 252.41(4)(a)1. respectively. Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m), Wisconsin Statutes].
Instructions: The parent / guardian shall fill out the form completely, sign it and submit it to the center prior to the child's first day of attendance. Information on this form shall be kept current. When enrolling a child under two years of age, a completed Intake for Child Under 2 Years form must also be on file prior to the child's first day of attendance.
Child Information
Name (first, last, MI)
*
First Name
Last Name, MI
Birth Date
*
-
Month
-
Day
Year
Date
Age at start of camp
*
Which week(s) of camp is your child attending? Please mark all weeks for which your child is registered! Please also check your registration confirmation email to confirm camp weeks are correct.
*
Critters Club (Week 1, 4-6 year olds)
Trail Trekkers (Week 1, 7-11 year olds)
Nature Detectives (Week 2, 4-6 year olds)
Boreal Pioneers (Week 2, 7-11 year olds)
Happy Hikers (Week 3, 4-6 year olds)
Mucky Ducks (Week 3, 7-11 year olds)
Tiny Twigs (Week 4, 4-6 year olds)
Ridges Rangers (Week 4, 7-11 year olds)
Climbing Caterpillars (Week 5, 4-6 year olds)
Mighty Monarchs (Week 5, 7-11 year olds)
Bug Me (Week 6, 4-6 year olds)
6-Legged Science (Week 6, 7-11 year olds)
First Day of Attendance
*
-
Month
-
Day
Year
Date
Parent or Guardian
PARENT OR GUARDIAN – All parents / guardians are permitted to visit during center hours and are allowed to pick up the child unless access is prohibited or restricted by a court order. Attach court order, if any. If the child resides at multiple locations, the department recommends the provider obtain and attach a schedule.
Parent / Guardian 1: Name
*
First Name
Last Name
Relationship to Child
*
Home / Cell Phone Number
*
Please enter a valid phone number.
Email Address Where Reachable While Child is in Care
*
example@example.com
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does Child Reside at This Location?
*
Yes
No
Place of Employment
*
Work Phone Number
*
Please enter a valid phone number.
Parent / Guardian 2: Name
*
First Name
Last Name
Relationship to Child
*
Home/ Cell Phone Numer
*
Please enter a valid phone number.
Email Address Where Reachable When Child is in Care
*
example@example.com
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does the child reside at this location?
*
Yes
No
Place of Employment
*
Work Phone Number
*
Please enter a valid phone number.
Authorized Person(s)
AUTHORIZED PERSONS – Persons other than parents / guardians who are authorized to pick up the child or accept the child if dropped off. If no one, write "None."
Person 1: Name
*
First Name
Last Name
Relationship to Child
*
Phone Number
*
Please enter a valid phone number.
Email Address Where Reachable While Child is in Care
*
example@example.com
Place of Employment
*
Work Phone Number
*
Please enter a valid phone number.
I authorize this person to pick up my child
*
Yes
No
Person 2: Name
First Name
Last Name
Relationship to Child
Phone Number
Please enter a valid phone number.
Email Where Reachable When Child is in Care
example@example.com
Place of Employment
Work Phone Number
Please enter a valid phone number.
I authorize this person to pick up my child
Yes
No
Emergency Contact
The person to be notified in an emergency when parents / guardians cannot be reached.
This person is authorized to pick up the child:
*
Yes
No
Name
*
First Name
Last Name
Relationship to Child
*
Phone Number
*
Please enter a valid phone number.
Email Address Where Reachable While Child is in Care
*
example@example.com
Place of Employment
*
Work Phone Number
*
Please enter a valid phone number.
Physician or Medical Facility
Note: You will need to complete the full Health History Form in addition to this section of the Enrollment Form.
Physician Name
*
First Name
Last Name
Medical Facility Name
*
Medical Facility Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Physician/ Medical Facility Phone Number
*
Please enter a valid phone number.
Fridays at Backpack Adventure Camp are Beach Days, during which campers hike down to the beach and play in the sand and water. We will have a trained lifeguard on duty. Children are not allowed to go in the water past their knees, regardless of age group or swimming ability. Because we allow children to go in the water, we need to know the level of swimming ability your child has.
*
My child cannot swim
My child can swim with assistance of floatation devices
My child can tread water
My child is comfortable swimming in a pool environment
My child is comfortable swimming in an open water environment such as a lake
Authorizations
I hereby give my consent for emergency medical care or treatment to be used only if I cannot be reached immediately
*
Yes
No
I have had an opportunity to review the policies of this child care center and a summary of the Wisconsin Rules for Licensing Child Care Centers.
*
Yes
No
I give permission for my child to participate in walking field trips and other activities during operating hours.
*
Yes
No
I have been informed of the number of pets in the center and their degree of contact with the enrolled children. Note: If pets are added after a child is enrolled, parents shall be notified in writing prior to the pet's addition to the center.
*
Yes
No
Ridges Photo Release
I grant to The Ridges Sanctuary, its representatives and employees, the right to take photographs of my child in connection with Backpack Adventure Camp. I authorize The Ridges Sanctuary to use and publish the same in print and/or electronically. I agree that The Ridges Sanctuary may use such photographs of my child with or without my name for any lawful purpose, including for example, such as publicity, illustration, advertising, and Web content.
*
Yes
No
The Ridges Sanctuary Backpack Adventure Camp will share a newsletter containing photos of campers participating in camp activities with registered Backpack Adventure Camp families during the week of their child's participation in the program. I grant The Ridges Sanctuary the right to take photographs of my child in connection with Backpack Adventure Camp and include them in the newsletter. I understand that the photos taken are to share the experiences of campers and are strictly for camp families.
Yes
No
Signature
Please make sure you have filled out this form completely and that all information is correct. By typing your name below, you agree to the above authorizations and the Photo Release statement (unless you have chosen "no" for the Photo Release, in which case The Ridges will not take photos of your child during camp programs).
Type Name Below
*
First Name
Last Name
Date of Signature
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: