Child Admission Record

Date of Enrollment:                                         

Child’s Name:                                                                                                                                       

General Information:

Date of Birth:                                                                                                                                     

Home Address:                                                                                                                                    

Phone Number:                                                                                                                                    

Father/Guardian Information:

Father or Guardian Name:                                                                                                                   

Father’s Contact Phone Numbers: __________________________________________________________

Address (if different from child):                                                                                                      ___

Employer Name:                                                                                                                                   

Employer Address:                                                                                                                              

Employer Phone Number:                                                                                                                     

E-mail Address:                                                                                                                                   

Mother/Guardian Information:

Mother or Guardian Name:                                                                                                                  

Mother’s Contact Phone Numbers:                                                                                                       

Address (if different from child):                                                                                                      

Employer Name:                                                                                                                                   

Employer Address:                                                                                                                              

Employer Phone Number:                                                                                                                       

E-mail Address:                                                                                                                                 _  
 

Emergency/Medical Information:

If neither parent or guardian can be reached in case of an emergency call: ____________________________

Child’s Doctor (name, address, phone):                                                                                                

Child’s Dentist (name, address, phone):                                                                                                

Child’s Hospital of Choice:                                                                                                                   

Insurance Information:                                                                                                                       

What illnesses has your child had in the past month?                                                                         

What treatment was given?                                                                                                                 

When was the last prescription medicine given to this child?                                                              

Has your child had any illness in the past 24 hours?                                                                            

If so, describe illness and treatment:                                                                                                    

Family/Home Information:

Other children in family (list relation):                                                                                               
____________________________________________________________________________________

Other adults in family (list relation):                                                                                                  

                                  __ _______________________________________________________________

Child Care Information:

Do you have a back-up provider?           Yes                   No

If yes, Name, address, and phone number:                                                                                          
______________________________________________________________________________________

Previous experience(s) in childcare (include dates):                                                                             
______________________________________________________________________________________

Are there any holidays you DO NOT want to participate in?                                                                

Are there any foods you DO NOT want your child to eat?                                                                   

Any other information about your family or child that you wish us to know:
______________________________________________________________________________________
______________________________________________________________________________________

Permission for Activities:

I/We hereby give Higher Ground Child Development Center permission to take my/our child,                          ,
off the premises and on excursions that will take place during regular childcare hours.  I understand that I will
be notified of any such trips beforehand, that trips will be supervised and that all precautions will be made for
the safety and well being of all the children.  I/We also understand that Higher Ground Child Development
Center will not be liable for any accident or injury.

Consent is for normal activities unless indicated below ~ the following activities may occur during the course of
the day at Higher Ground Child Development Center.

Please initial those activities your child does not have permission to participate in:
            Go for walks
            Ride a bike
            Play in water
            Go to a park
            Ride in wagon/stroller
            Go on field trips
 
Are there any other activities in which your child should not participate?

                                                                                                                           ______________________

Photo Permission:

I/We give permission for to use our child’s, ________________________,
photograph on the website, fliers, brochures, or any other publication relative to Higher Ground Child
Development Center.  We realize that our child's first or last name will not be used in such publications.

Child Release Information:

No child may be released from Higher Ground Child Development Center to any person other than
his/her parents or other person currently designated in writing by such parent to receive the child.
Those people authorized to pick-up the child (including parents) need to present photo identification
each day until easily recognized by the provider.

The following persons have my permission to pick up my child from the Center:

Name                                                                                        Phone                                                 

Relationship to child                                                                                                                           

Name                                                                                        Phone                                                 

Relationship to child                                                                                                                           

Name                                                                                        Phone                                                 

Relationship to child                                                                                                                           

Name                                                                                        Phone                                                 

Relationship to child                                                                                                                           

I/We certify that all of the information given on this form is correct and accurate to our best knowledge.  

I/We promise that I/we will notify the provider, if any or all of the information changes.

Mother’s Signature                                                                   Date

Father’s Signature                                                                    Date

Provider’s Signature                                                                 Date