HoopRank Registration

Child Information
Child #1 Name*

First NameMiddle NameLast Name
Name Child prefers to be called
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date*

MonthDayYear
SSN:
List any medical conditions, medication and/or special attention your child may require: *
Allergies: *
Pediatrician's Name:
Pediatrician's Phone Number

Area CodePhone Number
Pediatrician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional Comments
Child #2 Name

First NameMiddle NameLast Name
Name Child prefers to be called
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date

MonthDayYear
SSN:
List any medical conditions, medication and/or special attention your child may require:
Allergies:
Pediatrician's Name
Pediatrician's Phone Number

Area CodePhone Number
Pediatrician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional Comments
Child #3 Name

First NameMiddle NameLast Name
Name Child prefers to be called
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date

MonthDayYear
SSN:
List any medical conditions, medication and/or special attention your child may require:
Allergies:
Pediatrician's Name

First NameLast Name
Pediatrician's Phone Number

Area CodePhone Number
Pediatrician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional Comments
Child #4 Name

First NameMiddle NameLast Name
Name Child prefers to be called
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date

MonthDayYear
SSN:
List any medical conditions, medication and/or special attention your child may require:
Allergies:
Pediatrician's Name

First NameLast Name
Pediatrician's Phone Number

Area CodePhone Number
Pediatrician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional Comments

Emergency Contact and Authorized Pickup Persons
Contact 1 - Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship to Child*
Able to Pick Up Child

YesNo
Contact 2 - Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship to Child
Able to Pickup Child

YesNo
Contact 3 - Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship to Child
Able to Pickup Child

YesNo
Contact 4 - Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship to Child
Able to Pickup Child?

YesNo

Medical Information and Consent
Do all Children listed above have the same Doctor?

YesNo
Pediatrician's Name*
Pediatricians Phone Number*

Area CodePhone Number
Pediatricians Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Health Insurance Carrier
Health Insurance Policy # and Group ID #
I hereby voluntarily consent to the rendering of such care, including diagnostic procedures, surgical and medical treatment and blood transfusions, by medical doctors, hospitals or their authorized designees, as may in their professional judgement be necessary to provide for the medical, surgical or emergency care of the child/children listed on this form (hereafter “dependent”)

I further give my consent to HoopRank Early Education and Sports Academy and its employees and/or assigns who will be caring for my dependent for the period, to arrange for routine or emergency medical and/or dental care and treatment and obtain medical records necessary to preserve/improve the health of my dependent. In the event that my dependent is injured or ill while under the care of the caregiver, I hereby give permission to the caregiver to provide first aid for said dependent and to take the appropriate measures, including contacting the Emergency Medical Service (EMS) system and arranging for transportation to the nearest emergency medical facility.

In making medical decisions on my behalf for the benefit of my dependent, I direct that the caregiver attempt to contact me. However, if medical care becomes essential, I give permission to the caregiver to make such decisions regarding such treatment as deemed appropriate by the medical doctor, hospital or their authorized designee. In furtherance of any treatment decisions to be made by the caregiver on my behalf for the benefit of my dependent, I authorize the caregiver to request, obtain, review and inspect any and all information bearing upon my dependent’s health and relevant to any such decisions to be made respecting such treatment.

I acknowledge that no guarantees have been made to me as to the effect of such examinations or treatment on the condition of my dependent and that I am responsible for all charges in connection with the care and treatment rendered to my dependent during this period.
Signature*

Clear

Field Trip and Transport Permission
I understand that HoopRank Early Childhood and Sports Academy is an active school which will be participating in various activities throughout the year that require the transport of my child or require my child to walk to nearby destinations such as parks, playgrounds, basketball courts, lunches, breakfast, nature walks etc. I give HoopRank Early Education and Sports Academy permission to leave the Child Care Center Campus and go on field trips with the staff.
Signature*

Clear

Photo and Social Media
I give permission for my child to be photographed and video recorded by staff for record keeping, medication book, photo albums, portfolio social media, advertising and marketing purposes.

I also give permission for my child to be used in local newspapers, websites, social media accounts, print advertising and or as a video stream

This is a blanket permission slip for any day when my child is in attendance.
Signature*

Clear
I have downloaded the daycare center handbook and reviewed all policies.
Signature*

Clear

Tuition and Payment Information
Please outline below whom is responsible for payment of tuition and payment of tuition and fees. Please fill out if parents are divorced and split the tuition payment or if tuition payment is the responsibility of an adult other than the parents listed above.

Educational Background

Please explain in detail where necessary:
What things would you like to see HoopRank Focus on with your child?
What are your child's hobbies?
Are there behavioral issues that you would like HoopRank to work on with your child?
Is your child a picky eater?
Does your child currently take naps?
Should be Empty:

HoopRank Academy Family Enrollment

Parent/Guardian Information

Child Information

Emergency Contact and Authorized Pickup Persons

Medical Information and Consent

Field Trip and Transport Permission

Photo and Social Media

I have downloaded the daycare center handbook and reviewed all policies.

Tuition and Payment Information

Educational Background