All Enrollment FormsMake sure to film each individual form. Child's Name * First Name Last Name Birthdate * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Parent or Guardian #1 * First Name Last Name Parent or Guardian #1 Home Phone Number * (###) ### #### Parent or Guardian #1 Work Phone Number * (###) ### #### Parent or Guardian #1 Cell Phone Number * (###) ### #### Parent or Guardian #2 * First Name Last Name Parent or Guardian #2 Home Phone Number * (###) ### #### Parent or Guardian #2 Work Phone Number * (###) ### #### Parent or Guardian #2 Cell Phone * (###) ### #### Name * Emergency Contacts (To whom your child may be released to when parent or guardian cannot be reached) Written Permission must be on file for anyone other than a parent/guardian to pick up your child from the center. First Name Last Name Relationship (Emergency Contact #1) * Address * Emergency Contact #1 Address 1 Address 2 City State/Province Zip/Postal Code Country Home, Work, & Cell Phone Number * Emergency Contact #1 Name * Emergency Contact #2 First Name Last Name Relationship (Emergency Contact #2) * Address * Emergency Contact #2 Address 1 Address 2 City State/Province Zip/Postal Code Country Home, Work, & Cell Phone Number * Emergency Contact #2 Line Physician's Name * Child’s Primary Medical Care First Name Last Name Physician's Phone Number * (###) ### #### Physician's Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Hospital Address * In case of an emergency, preferred hospital to take your child to. Address 1 Address 2 City State/Province Zip/Postal Code Country Child's Health Insurance Plan Name * Certificate Number (or ID) # * Child’s Health Insurance Group # * Child’s Health Insurance Policy Holder's Name * Child’s Health Insurance Special Conditions, Disabilities, Allergies, or Medical Information for Emergency Situations: * Parent/Legal Guardian Consent and Agreement for Emergencies * As parent/guardian, I give consent to have my child receive first aid by facility staff, and, if necessary, be transported to receive emergency care. I understand that I will be responsible for all charges not covered by insurance. I agree to review and update this information whenever a change occurs and at least once a year. I give Consent I do not give Consent Parent/Guardian #1 * First Name Last Name Parent/Guardian #2 * First Name Last Name Date of Consent * MM DD YYYY Thank you!
