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    Childcare Registrationform

    Uploaded by

    api-316562499
    This child care registration form collects information about a child entering child care, including the child's name and date of birth, parent/guardian contact information, emergency contacts, medical information, and consent for emergency medical care. It gathers the child's basic identifying and emergency contact details, medical history and insurance coverage, and gets parental consent to authorize medical treatment in case of emergency.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Childcare Registrationform

    Uploaded by

    api-316562499
    154 views2 pages
    This child care registration form collects information about a child entering child care, including the child's name and date of birth, parent/guardian contact information, emergency contacts, medical information, and consent for emergency medical care. It gathers the child's basic identifying and emergency contact details, medical history and insurance coverage, and gets parental consent to authorize medical treatment in case of emergency.

    Original Title

    childcare registrationform

    Copyright

    © © All Rights Reserved

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    This child care registration form collects information about a child entering child care, including the child's name and date of birth, parent/guardian contact information, emergency contacts, medical information, and consent for emergency medical care. It gathers the child's basic identifying and emergency contact details, medical history and insurance coverage, and gets parental consent to authorize medical treatment in case of emergency.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    154 views2 pages

    Childcare Registrationform

    Uploaded by

    api-316562499
    This child care registration form collects information about a child entering child care, including the child's name and date of birth, parent/guardian contact information, emergency contacts, medical information, and consent for emergency medical care. It gathers the child's basic identifying and emergency contact details, medical history and insurance coverage, and gets parental consent to authorize medical treatment in case of emergency.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Date child entered care

    Child Care Registration Form


    Childs name

    Last

    First

    Middle

    Name (Nickname) used

    Street address

    City

    Childs parent/guardian name

    home phone #
    (
    )
    -

    Street address
    Address where you can be reached while child is in care
    Childs parent/guardian name

    home phone #
    (
    )
    -

    Address where you can be reached while child is in care

    Name

    cell phone#
    (
    )
    City

    cell phone#
    (
    )
    City
    City

    Birthdate
    Zip code

    City

    Street address

    Name:
    Relationship:

    Date child left care

    alternative phone #
    (
    )
    Zip code
    Zip code

    alternative phone #
    (
    )
    Zip code
    Zip code

    Other than you, who else has permission to pick up your child?
    Address
    Telephone number
    Home: (
    )
    Cell: (
    )
    Alternative: (
    )
    -

    Name:
    Relationship:

    Home: (
    )
    Cell: (
    )
    Alternative: (
    )
    Name:
    Home: (
    )
    Relationship:
    Cell: (
    )
    Alternative: (
    )
    Name:
    Home: (
    )
    Relationship:
    Cell: (
    )
    Alternative: (
    )
    In case of an emergency, I give permission for any of the following individuals to be contacted and my child may be
    released to any of them.
    Parent/Guardian signature:
    Name
    Name:
    Relationship:
    Name:
    Relationship:

    Name:
    Relationship:

    10.9.2.6 Child Care Registration Form


    Rev. 04/12

    Address

    Telephone number
    Home: (
    )
    Cell: (
    )
    Alternative: (
    )
    Home: (
    )
    Cell: (
    )
    Alternative: (
    Home: (
    )
    Cell: (
    )
    Alternative: (

    Who does not have permission to pick up your child? If applicable (A copy of supporting court document must be on file)
    Name
    Reason

    Date of childs last physical exam:


    Street address

    Childs health information


    Childs health care provider
    City

    Telephone number
    (
    )
    Zip code

    Special health problems?


    Yes or no? If yes, specify.

    Allergies, including drug reactions


    Yes or no? If yes, specify.

    Regular medications?
    Yes or no? If yes, specify.

    Other important information


    Yes or no? If yes, specify.

    Childs dentists name


    Street address

    City

    Telephone number
    (
    )
    Zip code

    Childs medical insurance coverage


    Member/policy number

    Insurance company name


    Policy holder name

    Employer name

    Insurance company name

    Member/policy number

    Policy holder name

    Employer name
    Consent to medical care and treatment of minor children

    I give permission that my child,____________________, may be given first aid/emergency treatment by a the child care
    licensee and/or qualified staff at:
    Name of Licensee

    Address of Licensee

    Parent/guardian signature

    Date

    Parent/guardian signature

    Date

    When I cannot be contacted, I authorize and consent to medical, surgical and hospital care, treatment and procedures to be
    performed for my child by a licensed physician, health care provider, hospital or aid car attendant when deemed necessary
    or advisable by the physician or aid car attendant to safeguard my child's health. I waive my right of informed consent to
    such treatment.
    I also give my permission for my child to be transported by ambulance or aid car to an emergency center for treatment.
    I certify under penalty of perjury under the laws of the State of Washington that this information is true and correct.
    Parent/guardian signature
    Date
    Parent/guardian signature
    Date

    10.9.2.6 Child Care Registration Form


    Rev. 04/12

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