World of Wonders: Child Enrollment Form
Child's Information
Child's Name
Date of Birth
-
Month
-
Day
Year
Date
First Day at Program
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent # 1 Information
Parent #1 Name
Parent #1 Primary Phone Number
Format: (000) 000-0000.
Parent #1 Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent #1 Email address
example@example.com
Parent #1 Additional Phone Number (Optional)
Format: (000) 000-0000.
Parent #1 Work/School Name
Check here if parent is unemployed or not in school
Parent #1 Work/School Phone
Format: (000) 000-0000.
Parent # 2 Information
Parent #2 Name
Check Here if Not Applicable
Parent #2 Primary Phone Number
Format: (000) 000-0000.
Parent #2 Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent #2 Email address
example@example.com
Parent #2 Additional Phone Number (Optional)
Format: (000) 000-0000.
Parent #2 Work/School Name
Check here if parent is unemployed or not in school
Parent #2 Work/School Phone
Format: (000) 000-0000.
Emergency Contacts
Primary Emergency Contact
This emergency contact must live within 60 minutes of the center and may not be a parent or guardian
Secondary Emergency Contact
Check here if Not Applicable
Primary Emergency Contact Name
Secondary Emergency Contact Name
Primary Emergency Contact Phone Number
Format: (000) 000-0000.
Secondary Emergency Contact Phone Number
Format: (000) 000-0000.
Primary Emergency Contact Other Number or Email Address (optional)
Secondary Emergency Contact Other Number or Email Address (optional)
My Child may be released to this emergency contact
Yes
No
My Child may be released to this emergency contact
Yes
No
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World of Wonders: Child Enrollment Form
Child Medical Information
Child's Name
Date of Birth
-
Month
-
Day
Year
Date
Does your child have a chronic health condition or diagnosis that requires the program to:
Rows
Yes
No
Observe or monitor for symptoms
Administer medication
Serve medical foods
Perform medical procedures
Avoid specific foods/environmental conditions and activities
Have a school aged child carry their own medication
*If any box has been checked yes, a completed Health Care Plan or documentation from a licensed physician, must be submitted prior to enrollment and annually.
Does your child need any medical, physical, developmental, behavioral, communication, or other accommodations or supports while participating in our program?
Yes
No
If yes, please explain and let us know how we can be most effective in meeting your child's needs:
Will any outside service providers work with your child at the program?
Yes
No
If yes, please provide the provider name, type of service, and schedule (Including Marysville Monarchs Academy):
Please provide a brief overview of your child's development, personality, behavior, routines, and individual needs. More detailed information may be provided in the Family Information Questionnaire included in this packet.
Emergency Transportation Authorization
Please select one. Please note: World of Wonders may be unable to provide care for children whose parents do not authorize emergency medical transportation.
World of Wonders has permission to secure emergency transportation for my child in the event of an illness or injury which requires emergency treatment. The emergency transportation service will determine the facility to which my child will be transported.
World of Wonders does not have permission to secure emergency transportation for my child in the event of an illness or injury which requires emergency treatment.
If you did not want emergency transport above, please list action to be taken.
Parent Siganture
This form must be reviewed every 12 months from the date of the parent acknowledgement.
By signing this form, I attest that the information is accurate and that I have reviewed and received a copy of the program's policies and procedures (parent handbook).
Parent Signature:
Date:
-
Month
-
Day
Year
Date
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