PARENT INTAKE FORM

Child’s Full Name:

Date of Birth:

Gender:

Program Type:

Full-Time Part-Time Drop-In

Start Date:

PARENT / GUARDIAN INFORMATION

Primary Guardian

Name:

Phone:

Email:

Address:

Secondary Guardian

Name:

Phone:

Email:

EMERGENCY CONTACTS (OTHER THAN PARENTS)

Name:

Relationship:

Phone:

HEALTH INFORMATION

Pediatrician Name:

Pediatrician Phone:

Allergies (food, medication, environmental):

Medical conditions:

Medications required during care:

Special needs or accommodations:

CONSENTS (INITIAL EACH)

I authorize emergency medical care if necessary I consent to participation in learning & play activities I acknowledge receipt of child care policies I agree to tuition and payment terms

PHOTO / MEDIA RELEASE (OPTIONAL)

Yes, I allow photos/videos for program use No, I do not consent

PARENT / GUARDIAN SIGNATURE

Signature:

Date

PARENT INTAKE FORM

Quick Links

Programs

Contact