Enrollment, Easy as 1, 2, 3
12 Reasons Parents Love Us
At the Oil Ranch
At the Circus
At the Zoo
Child’s Full Name
Date of Birth
Child’s Home Telephone No.
Child’s Home Address / Zip code
Date of Admission
Date of Withdrawal
Parent’s or Guardian’s Name
Address (if different from child’s address)
Mother’s Telephone No.
Father’s Telephone No.
Guardian’s Telephone No.
Cell Phone No
Give the name, address and phone number of person to call
in case of an emergency if parents / guardian cannot be reached:
Designated Person #1
Designated Person #2
Designated Person #3
Consent for my child to be transported
and supervised by the operation’s employees:
I hereby give consent.
I hereby DO NOT give consent.
for emergency care.
on field trips.
to and from home.
to and from school.
Consent for my child to participate in Field Trips:
I hereby give my consent
I hereby DO NOT give my consent
Consent for my child to participate
in Water Activities:
I hereby give my consent.
I hereby DO NOT give my consent.
Water table play
RECEIPT OF WRITTEN OPERATIONAL POLICIES:
I acknowledge receipt of the facility’s operational policies including those for discipline and guidance.
I UNDERSTAND THAT THE FOLLOWING MEALS WILL BE SERVED TO MY CHILD WHILE IN CARE:
MY CHILD IS NORMALLY IN CARE ON THE FOLLOWING DAYS AND TIMES:
Name of Physician:
Name of Emergency
Medical Care Facility:
I give consent for the facility to secure any and all necessary emergency medical care for my child.
List any special problems that your child may have, such as allergies, existing illness, previous serious illness, injuries and hospitalizations during the past 12 months, any medication prescribed for long-term continuous use, and any other information which caregiver’s should be aware of:
Signature – Parent or Legal Guardian
Date of Signature – Parent or Legal Guardian