Learning Days Registration Form

Child Name

First NameLast Name

Child Middle name

Child Birth Date

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Gender

Other

What is your race and / or ethnicity?

Hours of child care needed

School hours are 7:00 AM to 5:00 PM depending on the location

Do you require before or after school care?

Days of the week required

At Learning Days, we occasionally take photographs of the children during daily activities, events, and special projects. These photos may be used for classroom displays, portfolios, school newsletters, our website, or social media pages (e.g., Facebook or Instagram).

We value your privacy and ask for your permission to include your child in these photographs. Please complete the form below.

Picture / Video Permission

Parent Permission Form(OAR 414-305-0525(1) & OAR 414-305-1110(12))and OAR 414-305-0230(1)

Mother Name

First NameLast Name

Mother Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Mother Email Address

example@example.com

Mother Employer Name and address

Mother Work Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Please upload Mother Driving License/ Picture ID

Father Name

First NameLast Name

Father Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Father Email Address

example@example.com

Father Employer Name and address

Father Work Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Please upload Father Driving License

Parents Marital Status

If divorced who has legal Custody?

First NameLast Name

Please upload the copy of the Custoday.

Emergency Contact 1
In the event of an emergency, please contact:

Name

First NameLast Name

Relationship

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Please upload Picture

Who, besides yourself, is authorized to pick up your child from school?
Please list their full names, relationships, and phone numbers. You may also upload a photo of each person for identification purposes.

Name

First NameLast Name

Relationship

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Please Upload the picture

Name

First NameLast Name

Relationship

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Please Upload the picture

Doctor's Name

First NameLast Name

Doctor's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Dentist's Name

First NameLast Name

Dentist's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Preferred hospital

Health Insurance Name

Health Insurance ID or Policy

Health Insurance Card

Please list any of the following: Current medications, medication allergies, food allergies, or chronic health concerns.

Permission Form

I give permission to Learning Days and any employee 18 years or older to:

Authorize emergency medical treatment for my child if I cannot be reached.
Call an ambulance or take my child to a hospital at my expense.
Provide CPR or first aid in case of emergency.
Give prescribed and over-the-counter medication with my verbal or written consent.
Take my child on supervised walking field trips or excursions with verbal or written consent.

I Acknowledge

· I acknowledge that Learning Days provide the orientation to us at the tour of the childcare.

· My child can not stay longer than 10 hours per day during the business operation hours.

· I acknowledge if I arriving earlier or later than business operation hours, the following rates will be charge: $3.00 per Minute per Child.

· I acknowledge Payment is due in advance in full before child start.

· I acknowledge that there is no reduction of the payments due to child attendance such as child sick leave or vacation days, holidays, staff training closure or closure due to inclement weather, or any school closure.

· I acknowledge 30 days written notice in advance require for any leave and termination of the care. Failure to follow the 30 days’ notice will result in legal action including attorney and court fees.

· I acknowledge Learning Days may terminate the contract without giving notice if the parent/guardian does not make payments when the payment is due.

· Failure by the Learning Days to enforce one or more terms of the contract does not waive the rights of the Learning Days to enforce any other terms of the contract.

Signature:

By signing this contract, parent(s)/guardian(s) agree to the terms and have filled it out to the best of their knowledge. You also, agree to abide by the written policies of the Learning Days in Parent Handbook. The Learning Days may amend program policies and will be giving the parent(s)/guardian(s) a copy of the new or changed policies at least two weeks before they go into effect.

Mother Signature

Father Signature

Family Handbook Acknowledgement

Please sign this acknowledgement, detach it from the handbook, and return it to the center prior to enrollment.

This handbook may be updated from time-to-time, and notice will be provided as updates are implemented.

Thank you for your acknowledging the policies and procedures we have established for the safety and welfare of all children in our care. We look forward to getting to know you and your family.

I have received the Learning Days Family Handbook, and I have reviewed the family handbook with a member of the Learning Days staff. It is my responsibility to understand and familiarize myself with the Family Handbook and to ask center management for clarification of any policy, procedure or information contained in the Learning Days Family Handbook that I do not understand.

Signature

Date

Information of Parent

Medical Information