Enrollment Form

* Required Information

Entrance Date

Withdrawal Date

Child's Name *

Sex

Age *

Date of Birth *

Home Address (Street) *

City *

State

Zip

Home Phone Number *

Father’s Name

Home Phone Number

Father's Home Address (if different from child's) Street

City

State

Zip

Father's Place of Employment

Work Phone

Employer's Street Address

City

State

Zip

Mother’s Name

Home Phone Number

Mother's Home Address (if different from child's) Street

City

State

Zip

Mother's Place of Employment

Work Phone

Employer's Street Address

City

State

Zip

Child’s Living Arrangements

Both Parents

Mother

Father

Other

Child’s Legal Guardian(s)

Both Parents

Mother

Father

Other

The child may be released to the person(s) signing this agreement or to the following:

Name

Address

Telephone Number

Relationship to child

Relationship to Parent(s) or Guardian

Other identifying information (if any)

Name

Address

Telephone Number

Relationship to child

Relationship to Parent(s) or Guardian

Other identifying information (if any)

Persons to contact in the case of emergency when parent or guardian cannot be reached:

Name

Telephone Number

Name

Telephone Number

Name

Telephone Number

Name of Public or Private School child attends, if any

Child's doctor or clinic name

Doctos/Clinic Phone Number

My child has the following special needs

The following special accommodation(s) may be required to most effectively meet my child’s needs while at the center

My child is currently on medication(s) prescribed for long - term continuous use and/or has the following preexisting illness, allergies, or health concerns

Emergency Medical Authorization

Should(Child's Name)

Date of Birth

Suffer an injury or illness while in the care of (Facility name) Harmony Learning Academy and the facility is unable to contact me (us) immediately, it shall be authorized to secure such medical attention and care f or the child as may be necessary. I (We) shall assume responsibility for payment for services.

Parent/Guardian Name (Print)

Date

Facility Administrator/Person-In-Charge Name)

Date

Parental Agreements with Child Care Facility

The agrees to provide child care for on a.m. to p.m from to .

My child will participate in the following meal plan (circle applicable meals and snacks)

Before any medication is dispensed to my child, I will provide a written authorization, which includes: date; name of child; name of medication; prescription number; if any; dosages; date and time of day medication is to be given. Medicine will be in the original con tainer with my child's name marked on it.

My child will not be allowed to enter or leave the facility without being escorted by the parent(s), person authorized by parent (s), or facility personnel.

I acknowledge it is my responsibility to keep my child's records current to reflect any significant changes as they occur, e.g., telephone numbers, work location, emergency contacts, child's physician, child's health status, infant feeding plans and immunization records, etc.

The facility agrees to keep me informed of any incidents, including illnesses, injuries, adverse reactions to medications, etc., which include my child.

The agrees to obtain written authorization from me before my child participates in routine transportation, field trips, special activities away from the facility, and water-related activities occurring in water that is more than two (2) feet deep.

I authorize the child care facility to obtain emergency medical care for my child when I am not available.

I have received a copy and agree to abide by the policies and procedures for .

I understand that the facility will advise me of my child’s progress and issues relating to my child’s care as well as any individual practices concerning my child’s special needs. I also understand that my participation is encouraged in facility activities.

Name (Parent/Guardian)

Date

Name (Facility Administrator/Person-In-Charge)

Date

Breakfast	Morning Snack	Lunch
Afternoon Snack	Evening Snack Dinner	Bedtime Snack