Rocking Horse

Day Care Centers

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Rocking Horse Day Care Centers                                                               Enrollment Form

 

Complete and accurate information is necessary so that we may best serve your child.  It is your responsibility

to notify the center of any changes to employment, telephone numbers, child’s doctor, emergency contacts or

 persons authorized to pick up your child.

 

 

Admission Date: ____ / ____ / _______     Days of the Week: _____________      Hours: ______  -  _______

 

Child’s Name: ____________________________                         M  /  F                      Date of Birth: ____ / ____ / _______

 

Address: _________________________________                        Home #: _________________________

 

City: _____________________         State: ______         Zip: _____________

 

Father’s E-Mail: _________________________________________

 

Mother’s E-Mail: _________________________________________

 

 

Father’s Name: ____________________________                       TDL# _________________________

 

Address: _________________________________                        Home #: _________________________

 

City: _____________________  State: ______  Zip: __________             Cell #: ___________________________

 

Employer: ______________________________________                          Work #: ____________________________

 

 

Mother’s Name: ____________________________                      TDL# _________________________

 

Address: _________________________________                        Home #: _________________________

 

City: _____________________  State: ______  Zip: __________             Cell #: ___________________________

 

Employer: ______________________________________                          Work #: ____________________________

 

The following people may be contacted if I / We cannot be located in the event of an emergency and are also authorized to pick up my child from the center (We must have a copy of their drivers license on file) :

 

Name: ______________________________  Address:_____________________________________________

 

   Home #: ____________________                   Work #: _____________________                 Cell #_______________________

 

Name: ______________________________ Address:______________________________________________

 

   Home #: ____________________                   Work #: _____________________                 Cell #_______________________

 

Name: ______________________________ Address:______________________________________________

 

    Home #: ____________________                  Work #: _____________________                 Cell #_______________________

 

Name: ______________________________Address:_______________________________________________

 

   Home #: ____________________                   Work #: _____________________                 Cell #_______________________

TRANSPORTATION: I hereby ____ give ____ do not give my consent for my child to be transported and

 

                                                    supervised by facility staff: _____ on field trips            _____ to and from school

 

WATER ACTIVITIES: I hereby ____ give ____ do not give my consent for my child to participate in water

 

  activities.

 

PICTURES: I hereby ____ give ____ do not give my consent for my child to have their picture taken for class

 

projects, seasonal holidays, graduation, etc. and that the pictures can be posted on bulletin

 

 boards, walls, etc.

 

OPERATIONAL POLICIES: I acknowledge being given a copy of the Operational Policies.

 

________________________________________                         ______   / ______  /  __________

 

Signature  –  Parent / Guardian                                                                 Date                         

 

 

 

 

SCHOOL-AGE CHILDREN: My child attends: _______________________________________ School

 

                                                  School Phone: ________________________________

 

                                                  School Address: __________________________________

 

My child’s immunization records are on file at the school and all immunizations are current. ____ yes  ____ n / a

 

 

 

SPECIAL HEALTH CONCERNS

 

List any special problems that your child may have, such as allergies, existing illness, previous serious illness, injuries during the past 12 months, any medication prescribed for long-term continuous use, and any other info:

 

 


 


 


 

 

Varicella ( chickenpox ) vaccine is required if your child has not had chickenpox.  If your child has had chickenpox, please complete this statement:  My child had chickenpox on or about  ____ / _______ and doesn’t need the vaccine.

 

Rocking Horse Day Care Center has my permission to give Tylenol or its equivalent for fever.

 

 

________________________________________                         ____   / ____  /  ________

 

                                                   Signature  –  Parent / Guardian                                                                      Date                              

 

 

 

AUTHORIZATION FOR EMERGENCY MEDICAL ATTENTION

 

In the event that I can not be reached to make arrangements for emergency medical attention, I authorize the facility director or person in charge to take my child to:

 

 

Licensed Physician: ________________________________Address: _________________________________

 

Phone # _____________________________                          ________________________________________

 

or Hospital / Clinic: ________________________________Address: _________________________________

 

Phone # _____________________________                                  _____________________________________

 

I hereby give my consent for necessary emergency treatment when my child is in care of this physician

and / or hospital / clinic.

 

________________________________________                         ____   / ____  /  ________

 

                                                   Signature  –  Parent / Guardian                                                                      Date                              

 

 

ADMISSION REQUIREMENT: Check to indicate the option you select.

 

_____ Parent’s Statement: My child has been examined within the past year by a licensed physician and is able

 to participate in the day care program.

                                           

__________________________________

 

                                                                    Physician’s Name                

 

_____ My child has an appointment for a physical examination.  I will submit a physician’s statement, EPSDT

 form, or health service or clinic form to the day care.

                 

________________________________________                         ____   / ____  /  ________

 

                                                   Signature  –  Parent / Guardian                                                                   Date