Scribbles & Giggles Child Care Registration Form

Registration Fee $25.00 (One Time Only & Non-Refundable)

Registration Date: 🛈

Desired Start Date: *

Family Information

Child's Name *

Birth Date * +

Allergies *

Child's Name

Birth Date +

Allergies

Child's Name

Birth Date +

Allergies

Mother/Guardian Information

First Name *

Last Name *

Email Address *

Address *

City *

State *

Zip *

Phone # *

Alternate Phone #

Employer *

Work Address *

Work Phone # *

Father/Guardian Information

First Name *

Last Name *

Email Address *

Address *

City *

State *

Zip *

Phone # *

Alternate Phone #

Employer *

Work Address *

Work Phone # *

Additional Information

Photo Release: Some photo's of the children may
be uploaded to S&G's Facebook or posted on our
website. Does S&G have your permission? *

Topical Non-Prescription Medication Permission *

S&G has my permission to apply insect repellant (provided by parent)

S&G has my permission to apply diaper rash cream (provided by parent)

S&G has my permission to apply antibiotic ointment (provided by parent)

S&G has my permission to apply sunscreen (provided by S&G, additional $5.00 fee yearly)

I will provide my own sunscreen

Emergency Contacts & Authorized Pick Up List

Name *

Phone # *

Relationship to the child: *

Name *

Phone # *

Relationship to the child: *

Name

Phone #

Relationship to the child:

Name

Phone #

Relationship to the child:

Important Information

Immunization Record:

Upon enrollment, 1 of the following must be received:

(1) A certificate of immunization showing a minimum of 1 dose of each immunizing agent specified by the department of community health.

(2) A copy of a waiver addressed to the department of community health and signed by the parent stating immunizations are not being administered due to religious, medical, or other reasons.

If we do not receive the correct paper work, your child/children will not be able to attend until it is received in the office.

Acknowledgment

I agree that I have read and received the Parent Handbook and information packet containing additional policies and procedures. This institution is an equal opportunity provider.

Signature: *

clear

Date: *