Child Registration Form

Our curriculum is the Teaching Strategies GOLD curriculum; an authentic, ongoing observational system for assessing children from birth through kindergarten.

Start Date

End Date

Child's Name

Nickname

Date of Birth

Sex

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

Address

Cell Phone

Place Employed

Business Address

Business Phone

PARENT(S)/GUARDIAN(S) #2

Name

Relationship

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 CDC 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 CDC 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 CDC 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 CDC 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

Clear

Date

Parent(s) or Guardian(s) #2

Clear

Date

Center Administrator

Clear

Date

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