Uniquely Me Enrollment

Uniquely Me Enrollment

Second Baptist Church Childcare enrollment form for parents to complete online. Please provide child, family, schedule, emergency contact, medical, and consent information.
Child Information
Child 1 Full Name
Child 1 Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child 1 Preferred Nickname
Child 2 Full Name
Child 2 Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child 2 Preferred Nickname
Enrollment Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Disenrollment Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child Lives With
Child Health, Allergies, Development, Experience, Food, Toileting, Home, and Interests
Family Address and Contact Information
Household Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City / State / ZIP
Mailing Address (if different)
Preferred Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Guardian 1 Name

First NameMiddle NameLast Name
Guardian 2 Name

First NameMiddle NameLast Name
Guardian 1 Street Address
Guardian 1 City / State / ZIP
Guardian 1 Details
Guardian 1 Name

First NameMiddle NameLast Name
Street Address
City, State, ZIP
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
E-mail Address
example@example.com
Workplace
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Extension
Guardian 2 Details
Guardian 2 Name

First NameMiddle NameLast Name
Street Address
City / State / ZIP
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
E-mail Address
example@example.com
Workplace
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Extension
Childcare Schedule
Sunday Drop-off Time

Hour Minutes

AM/PM Option
Sunday Pick-up Time

Hour Minutes

AM/PM Option
Monday Drop-off Time

Hour Minutes

AM/PM Option
Monday Pick-up Time

Hour Minutes

AM/PM Option
Tuesday Drop-off Time

Hour Minutes

AM/PM Option
Tuesday Pick-up Time

Hour Minutes

AM/PM Option
Wednesday Drop-off Time

Hour Minutes

AM/PM Option
Wednesday Pick-up Time

Hour Minutes

AM/PM Option
Thursday Drop-off Time

Hour Minutes

AM/PM Option
Thursday Pick-up Time

Hour Minutes

AM/PM Option
Friday Drop-off Time

Hour Minutes

AM/PM Option
Friday Pick-up Time

Hour Minutes

AM/PM Option
Saturday Drop-off Time

Hour Minutes

AM/PM Option
Saturday Pick-up Time

Hour Minutes

AM/PM Option
Emergency Contacts and Authorized Pickup
Emergency Contact 1 Name
Emergency Contact 1 Relationship
Emergency Contact 1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 1 Alternate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 1 Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact 2 Name
Emergency Contact 2 Relationship
Emergency Contact 2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 2 Alternate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 2 Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact 3 Name
Emergency Contact 3 Relationship
Emergency Contact 3 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 3 Alternate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 3 Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact 4 Name
Emergency Contact 4 Relationship
Emergency Contact 4 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 4 Alternate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 4 Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Additional Authorized Pick-Up Person 1 Name
Additional Authorized Pick-Up Person 1 Relationship
Additional Authorized Pick-Up Person 1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Additional Authorized Pick-Up Person 2 Name
Additional Authorized Pick-Up Person 2 Relationship
Additional Authorized Pick-Up Person 2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Back Up Care Provider Name
Back Up Care Provider Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Back Up Care Provider Alternate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Person NOT Authorized 1 Name
Person NOT Authorized 1 Relationship
Person NOT Authorized 1 Notes
Person NOT Authorized 2 Name
Person NOT Authorized 2 Relationship
Person NOT Authorized 2 Notes
Medical, Insurance, and Health Information
Health Insurance Provider
Medical Provider Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Immunizations Up to Date
Medical and Health Notes
Required Signatures and Consents
Guardian Signature for Emergency Contacts Authorization
Date for Emergency Contacts Authorization

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Guardian Signature for Consent for First Aid
Date for First Aid Consent

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Guardian Signature for Emergency Medical Care Consent
Date for Emergency Medical Care Consent

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Uniquely Me Enrollment

Child Information

Family Address and Contact Information

Guardian 1 Details

Guardian 2 Details

Childcare Schedule

Emergency Contacts and Authorized Pickup

Medical, Insurance, and Health Information

Required Signatures and Consents