Enrollment Form

Child's Information

Child's Name

Date of Birth

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Allergies

Comforting Items

Special Instructions

#1 Parent/Guardian Information

Name

Relationship

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Home Phone

Cell Phone

#1 Parent/Guardian Email

Work Place

Work #

#2 Parent/Guardian Information

Name

Relationship

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Home Phone

Cell Phone

#2 Parent/Guardian Email

Work Place

Work #

If parent/guardian cannot be reached in the event of an emergency;

#1 Emergency Contact

Name

Relationship

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Home #

Cell #

Email

Work Place

Work #

#2 Emergency Contact

Name

Relationship

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Home #

Cell #

Email

Work Place

Work #

#3 Emergency Contact

Name

Relationship

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Home #

Cell #

Email

Work Place

Work #

Sign & Date

Signature and date for child, guardian, and emergency contact info.

Signature

Use your mouse or track pad on a computer or your finger on a phone to sign.

Date

Permission to Secure Emergency Care

I, ______________________ (parent or guardian), give my permission to St. Teresa of Calcutta Child Care Center to secure and authorize such emergency medical care and treatment as my child might require while under the Provider’s supervision. I also authorize the Provider to administer emergency care or treatment as required, until emergency medical assistance arrives. I also agree to pay all the costs and fees contingent on any emergency medical care and treatment for my child as secured or authorized under this consent.

Parent or Guardian Name

This field will be inputted into the above agreement.

Medical Information

All areas must be completed

Child’s Doctor

Phone #

Doctor Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Dentist (or Prospective)

Phone #

Dentist Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Please submit your child’s most recent immunization record and physical.

Does your child have any special needs that the center needs to be aware of?

Authorized Pick Up List

Person 1 Name

Person 1 Relationship

Person 1 Phone #

Person 2 Name

Person 2 Relationship

Person 2 Phone #

Person 3 Name

Person 3 Relationship

Person 3 Phone #

Person 4 Name

Person 4 Relationship

Person 4 Phone #

Person 5 Name

Person 5 Relationship

Person 5 Phone #

Person 6 Name

Person 6 Relationship

Person 6 Phone #

Anyone NOT Allowed to pick up the child

With court order, if applicable

Sign & Date

Signature and date for emergency care and pickup information.

Signature

Use your mouse or track pad on a computer or your finger on a phone to sign.

Date

Consent is given for selected items below:

Photo Release

Accept
Decline

Accept: My child may be photographed while in child care.

Decline: Do not photograph my child while in the child care program.

Photos may be used in newspapers or other media for the other families whose children attend the child care program.

Walking Trips in town

Accept
Decline

Motor Vehicle Trips (Field Trips)

Accept
Decline

Type of vehicles (Buses, cars, etc)

Restraint system to be used

Swimming and/or wading

Accept
Decline

Preschool/school-aged summer field trips to Calmar Pool

Trips to Ossian Parks

Accept
Decline

Enrollment Checklist

Sign & Date

Signature and date for consent.

Signature

Use your mouse or track pad on a computer or your finger on a phone to sign.

Date

Child's Information

#1 Parent/Guardian Information

#2 Parent/Guardian Information

#1 Emergency Contact

#2 Emergency Contact

#3 Emergency Contact

Sign & Date

Permission to Secure Emergency Care

Medical Information

Authorized Pick Up List

Sign & Date

Consent is given for selected items below:

Sign & Date

Ossian Site

Childcare Center

Calmar Preschool

Spillville Site