The Olde Schoolhouse of Burnt Hills, N.Y. Daycare Registration Form
Please print and complete this form and bring with you for enrollment.
CHILD BEING ENROLLED
Last Name:
First Name Middle Name:
Nickname:
Birth Date: Start Date:
NAMES OF SIBLINGS & BIRTH DATES:

 

PARENTS OR GUARDIANS
(1) Last Name: First Name:
Relationship to Child:
Address:
City: Postal Code:
Home Phone: Work Phone:
Employer:
(2) Last Name: First Name:
Relationship to Child:
Address:
City: Postal Code:
Home Phone: Work Phone:
Employer:
OTHER EMERGENCY CONTACT
Name: Relationship to Child:
Home Phone: Work Phone:
AUTHORIZATION FOR PICKUP
Your child will only be released to an authorized person listed on this form (parent/guardian and/or emergency contact).   In case of an emergency or an unforeseen circumstance, please indicate the name, address and phone number of any other person/s who you authorize to pickup your child on your behalf. 
  Name                                             Address                                         Phone
. . .
. . .
. . .

A parent/guardian's verbal authorization for pickup must be received before your child will be released to anyone not listed here.  If not received, and we cannot notify you by phone, the child will not be released.

MEDICAL INFORMATION
Doctor Office Phone
Address
City: Postal Code
Medical Ins. # Child's Personal ID#:
Allergies:
Medical Problems: 
Medication:
ADDITIONAL INFORMATION: Please indicate likes/dislikes, potty training, special interests, etc.
IMMUNIZATION:
The Health Unit now requires that we have a photocopy of your child's recent immunization record in our files.  Please include a photocopy with this registration form.  If you do not have the records, a copy can be obtained from your local health unit.
EMERGENCY CONSENT:
It is our policy of  to notify a parent when a child is ill or needs medical attention.  Occasionally, we cannot contact a parent and we need to get immediate help for the child.  Our procedure is to take the child to the nearest emergency service.

Please sign below so that we can take appropriate action on behalf of your child.

I HEREBY GIVE MY/OUR CONSENT FOR MY/OUR CHILD ______________________________
WHEN  ILL/INJURED, TO BE TAKEN TO THE NEAREST EMERGENCY CENTER BY THE STAFF OF MY CHILD'S DAYCARE WHEN I/WE CANNOT BE CONTACTED.  I CONSENT TO AN AMBULANCE BEING CALLED TO TRANSPORT THE CHILD, IF NECESSARY.  I FURTHER AGREE TO PAY ALL COSTS INCURRED FOR TRANSPORT.
 
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       Parent/Guardian Signature                             Parent/Guardian Signature
. .

          Date:                                                                   Date: