ENROLLMENT FORM

Please list 3 local individuals to contact in the event of an emergency

My child attends the following school:

In the event I cannot be reached to make arrangements for emergency medical care, I authorize the person in charge to take my child to:

My child will normally be in attendance the follow days and times:

List any special problems that your child may have, such as allergies, existing illness, previous serious illness, injuries and hospitalizations during that past 12 months, and medication prescribed for long-term continuous use, and any other information which caregivers should be aware of:

From time to time our facility may take photographs for educational use. I give consent for the facility to take photographs of my child.

I understand that the staff at this facility are prohibited in participating in outside employment with parents.

I understand that the staff at this facility are prohibited in participating in social networking activities with parents and children enrolled at the facility. (Such as Facebook, MySpace, and Twitter)