Primer Academia Registration Form

Emergency Contacts

(Within 20 mile radius of church other than parent or guardian)
Primary Emergency Contact (other than parents or guardian)*
Home Phone*
Work Phone*
Relationship to Child*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Secondary Emergency Contact (other than parents or guardian)*
Home Phone
Work Phone
Address

Street Address

Street Address Line 2

CityState

Zip Code
Person (s) authorized to pick up my child: (Besides parents, guardians, or emergency pickups)

**Please have I.D. to pick up child unless the parent or guardian.**
Name*
Secret Code*
(Secret word between parent & adult for identification and pick up)
Person(s) NOT authorized to pick up my child: (Besides parents, guardians, or emergency pick ups)
Name
Comment
Please list 5 adjectives about your child*

Emergency Release

Consent to Emergency First Aid & Transportation:

I hereby give permission that my child, may be given emergency treatment by a staff member at Primer Academia de ABC Spanish Immersion Program. I also give permission for my child to be transported by car, ambulance, or Aid car to an emergency center for treatment, and agree to hold Ana Cardona and its employees harmless.
Child's name*

First NameLast Name
Parent's Signature*

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Date*

MonthDayYear
**Parent will be contacted as soon as possible if an accident occurs.**
Consent to Medical Care and Treatment: In the event that I cannot be contacted immediately, medical of surgical treatment can be administered to my child in the case of an accident or emergency, as prescribed by a treating physician, and hold Ana Cardona and Primer Academia de ABC Spanish Immersion Program its employees harmless.
Parent's Signature*

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Date*

MonthDayYear
Emergency Information
Child’s Physician*
Phone Number*
Preferred Hospital*
Phone Number*
Insurance Company*
Policy #*
Regular Medications*
Blood Type*
Medicine allergic to*
Food Allergies*
Any other Allergies*
Any special health conditions*

About Your Child
What FOODS does your child especially like? *
Especially DISLIKE?*
Favorite toys, games, activities?*
Is your child TOILET TRAINED?*
*ALL CHILDREN 3 YEARS OLD AND UP MUST BE POTTY TRAINED*
What words does your child use for toilet? *
How does your child express ANGER or frustration? *
Does your child have any special FEARS? *
Explain
When your child is upset, what helps to COMFORT him/her? *
How do you DISCIPLINE your child? *
Has your child been taking an afternoon NAP?*
If so, how long?
If not, why?
Special toy or blanket for NAP?
Special FAMILY situations?
(such as custody specifications, problems arising from situations, etc.)
Anticipated ADJUSTMENT problems?
Any disorders/developmental (slow, advanced) diagnosed or suspected?*
Previous childcare child has attended*
Any problems at previous daycares?
EXPECTATIONS
Other COMMENTS?

Registration Form