Child's Full Name
*
Child's Preferred Name
Program (check one)
*
Button Willow (18m-2y)
Little Bluestem 2's
Little Bluestem 3's
Southern Sundrop (4's)
Honeysuckle (5's)
Schedule (check all that apply)
*
T/TH 9am-1pm
T/TH 9am-3:30pm
MWF 9am-1pm
MWF 9am-3:30pm
M-F 9am-1pm
M-F 9am-3:30pm
Black-Eyed Susan Program: 7:00am-9:00am
Brown-Eyed Susan Program: 3:30pm-6:00pm
Sex
*
Female
Male
Child's Birthday
*
MM
DD
YYYY
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone Number
*
(###)
###
####
Email
*
Parent / Guardian 1 Name
*
First Name
Last Name
Parent / Guardian 1 Occupation
*
Business Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Business Phone Number
*
(###)
###
####
Mobile Phone Number
*
(###)
###
####
Parent / Guardian 2 Name
First Name
Last Name
Parent / Guardian 2 Occupation
Business Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Business Phone Number
(###)
###
####
Mobile Phone Number
(###)
###
####
Marital Status
Married
Separated
Divorced
Other
Persons Authorized to Pick Up Your Child
*
Persons NOT Authorized to Pick Up Your Child
*
Please list all other persons & age living in child's household:
Please list all chronic physical problems, allergies, or intolerances - symptoms and action to be taken
Child's Physician
*
First Name
Last Name
Physician Phone Number
*
(###)
###
####
Emergency Contact 1 (other than parent)
*
First Name
Last Name
Emergency Contact 1 Address 3
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact 1 Phone Number
*
(###)
###
####
Emergency Contact 2 (other than parent)
*
First Name
Last Name
Emergency Contact 2 Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact 2 Phone Number
*
(###)
###
####
Has your child had any play experience?
*
Yes
No
Has your child had any school experience?
*
Yes
No
If answered yes, please list all previous schools your child has attended
*
Does your child nap?
*
Yes
No
Is your child toilet trained?
*
Yes
No
What time does your child go to bed?
*
Are there any dietary restrictions?
*
What are your child's favorite outdoor activities?
*
What are your child's favorite indoor activities?
*
Does your child have any speech problems?
*
Does your child have a security item?
*
Please list any medications your child takes?
*
What method of discipline do you use at home?
*
How would you best describe your child's personality?
*
How did you hear about us?
1) Friend / family member
2) Facebook / Instagram
3) Inlet Fitness Advertisement
4) Tidewater Family Magazine
5) Military Bridge
6) Back Bay Living Magazine
7) Online / Website
8) Other
Please read this section and sign on your child's first day of school
The child day center agrees to notify parent(s)/guardian(s) whenever the child becomes ill and parent(s)/guardian(s) will arrange to have the child picked up as soon as possible if so requested by the center.
The parent(s)/guardian(s) authorize the child day center to obtain immediate medical care if any emergency occurs when the parent(s)/guardian(s) cannot be located immediately. ‡
The parent(s)/guardian(s) agree to inform the center within 24 hours or the next business day after his child or any member of the immediate household has developed a reportable communicable disease, as defined by the State Board of Health, except for life threatening diseases which must be reported immediately.
Registration is non-refundable.
By submitting this form, the parent(s) agree to the policies explained in the Parent Handbook.
† Appropriate paperwork, such as custody paperwork, shall be attached if a parent is not allowed to pick up the child.NOTE: Section 22.1-4.3 of the Code of Virginia states that unless a court order has been issued to the contrary, the noncustodial parent of a student enrolled in a public school or day care center must be included, upon the request of such noncustodial parent, as an emergency contact for events occurring during school or day care activities.
‡ If there is an objection to seeking emergency medical care, a statement should be obtained for the parent(s) or guardian(s) that states the objection and the reason for the objection.
Proof of the child's identity and age may include a certified copy of the child's birth certificate, birth registration card, notification of birth (hospital, physician or midwife record), passport, copy of placement agreement or other proof of the child's identity from a child placing agency (foster care and adoption agencies), record form a public school in Virginia, certification by a principal or his designee of a public school in the U.S. that a certified copy of the child's birth record was previously presented or copy of the entrustment agreement conferring temporary legal custody of a child to an independent foster parent. Viewing the child's proof of identity is not necessary when the child attends a public school in Virginia and the center assumes responsibility for the child directly from the school (i.e., after school program) or center transfers responsibility of the child directly to the school (i.e., before school program). While programs are not required to keep the proof of the child's identity, documentation of viewing this information must be maintained for each child.
Section 63.2-1809 of the Code of Virginia states that the proof of identity, if reproduced or retained by the child day program or both, shall be destroyed upon the conclusion of the requisite period of retention. The procedures for disposal, physical destruction or other disposition of the proof of identity containing social security numbers shall include all reasonable steps to destroy documents my (i) shredding, (ii) erasing, (iii) otherwise modifying the social security numbers in those records to make them readable or indecipherable by any means.
