Child Registration Form Child Registration Form Start Date End Date Child's Name * Nickname * Date of Birth * Sex SexMaleFemale Address Home Phone Previous Child Day Care Programs Attended If Child attends this center and another School/Program, give name of school/program including Grade number Chronic Physical Problems/Pertinent Developmental Information/Special Accommodations Needed PARENT(S)/GUARDIAN(S) #1 Name * Relationship RelationshipMotherFatherLegal Guardian Email Address Cell Phone Place Employed Business Address Business Phone PARENT(S)/GUARDIAN(S) #2 Name * Relationship RelationshipMotherFatherLegal Guardian Email Address Cell Phone Place Employed Business Address Business Phone EMERGENCY INFORMATION (if parents cannot be reached) List any Allergies, Dietary Restrictions or Intolerance to Food/Medication etc, Action to take in an Emergency: Child’s Physician Physician's Phone Emergency Contact #1 Name Relationship to Child Emergency Contact #1 Phone Emergency Contact #1 Address Emergency Contact #2 Name Relationship to Child Emergency Contact #2 Phone Emergency Contact #1 Address Person(s) NOT Authorized to Pick Up Child* *Appropriate paperwork such as custody papers shall be attached if a parent is not allowed to pick up the child. NOTE that 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. Person(s) Authorized to Pick Up Child IDENTITY VERIFICATION Place of Birth Birth Date Birth Certificate Number Date Issued Other Form of Proof Date Viewed Person Viewing Document Date of Notification of Local Law-Enforcement Agency (when required proof of identity is not provided): AGREEMENTS Vine & Branches Childcare Center agrees to notify the parent(s)/guardian(s) whenever the child becomes ill and the parent(s)/guardian(s) will arrange to have the child picked up within one hour. The parent(s)/guardian(s) authorize Vine & Branches Childcare Center to obtain immediate medical care if any emergency occurs when the parent(s)/guardian(s) cannot be located immediately.****If there is an objection to this you must provide us with a statement stating the objection and the reason for objection 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. 4. The parent(s)/guardian(s) authorize Vine & Branches Childcare Center to release photographs of his child, which can be used for the following purposes (initial all that apply below): Within the school, on bulletin boards and in class pictures sent to other classroom parents via email and the parent portal Outside of the school for marketing purposes and on social media sites. I do NOT permit Vine & Branches CDC to release photographs of my child under any circumstance internally or externally. 5. The parent(s)/guardian(s) authorize Vine & Branches Childcare Center to release our contact information (email addresses) to the other parents in our child’s classroom(s). We Accept We Decline SIGNATURES Parent(s) or Guardian(s) #1 signature keyboard Clear Date Parent(s) or Guardian(s) #2 signature keyboard Clear Date Center Administrator signature keyboard Clear Date How did you hear about Vine & Branches? Submit If you are human, leave this field blank.
