Giraffe Laugh Early Learning Centers

GIRAFFE LAUGH EARLY LEARNING CENTERS

IDENTIFICATION AND EMERGENCY INFORMATION

NAME OF CHILD______DATE OF BIRTH___/___/___

NAME OF CHILD______DATE OF BIRTH___/___/___

HOME ADDRESS______CITY______STATE___ZIP______

MOTHER OR GUARDIAN______SS#_____-_____-_____

HOME ADDRESS______CITY______STATE___ZIP______

HOME PHONE NUMBER (____)-______-______CELL (____)-_____-______

EMPLOYER______PHONE(____)-_____-______

EMAIL______

FATHER OR GUARDIAN______SS#____-_____-_____

HOME ADDRESS______CITY______STATE___ZIP______

HOME PHONE NUMBER (____)-______-______CELL (____)-_____-______

EMPLOYER______PHONE(____)-_____-______

EMAIL______

PARTY RESONSIBLE FOR PAYMENT OF TUITION______

*IF EITHER PARENT IS A STUDENT, PLEASE LIST NAME OF SCHOOL AND PHONE AND ATTACH A COPY OF CURRENT SCHEDULE.

NAME OF SCHOOL______PHONE (____)-_____-_____

PERSON TO BE CALLED IN CASE OF EMERGENCY

WE WILL ALWAYS CALL THE PARENTS FIRST, PLEASE LIST SOMEONE OTHER THAN YOURSELF WHO MAY BE AVAILABLE IN AN EMERGENCY.

1-NAME______PHONE (____)-_____-______OR (____)-____-______

2-NAME______PHONE (____)-_____-______OR (____)-____-______

*UNDER NO CIRCUMSTANCES WILL A CHILD BE RELEASED TO ANYONE NOT KNOWN TO THE CENTER WITHOUT AUTHORIZATION FROM PARENTS OR GUARDIAN. PHOTO I.D. WILL BE REQUIRED WHEN SOMEONE NEW FRIST PICKS UP YOUR CHILD.

PERSONAL INFORMATION AND MEDICAL HISTORY

EMERGENY HOSPITAL PREFERENCE______

CHILD’S PHYSICIAN______PHONE (____)____-______

CHILD’S DENTIST______PHONE (____)-______-______

MARITAL STATUS OF PARENTS______

CUSTODY/VISITING ARRANGEMENTS______

OTHER MEMBERS OF HOUSEHOLD: (PLEASE INCLUDE RELATIONSHIP AND AGE)______

ANY DIETARY RESTRICTIONS?______

IS THE FAMILY VEGETARIAN?______

DOES YOUR CHILD HAVE ALLERGIES?______IF SO HOW DOES IT MANIFEST ITSELF? ASTHMA_____ HAY FEVER______HIVES______OTHER______

DO YOU KNOW WHAT CAUSES THE ALLERGY?______

ARE THERE ANY SERIOUS PROBLEMS WE SHOULD BE AWARE OF?______

I HEREBY GRANT PERMISSION FOR MY CHILD TO USE ALL OF THE PLAY EQUIPMENT AND PARTICIPATE IN ALL OF THE ACTIVITIES OF THE CENTER INCLUDING FIELD TRIPS. I HEREBY GRANT PERMISSION FOR THE DIRECTOR OR ACTING DIRECTOR TO TAKE WHATEVER STEPS MAY BE NECESSRY TO OBTAIN EMERGENCY MEDICAL CARE IF WARRENTED.

I ACKNOWLEDGE THAT THE CENTER WILL NOT BE RESPONSIBLE FOR ANYTHING THAT MAY HAPPEN AS A RESULT OF FALSE OR INCOMPLETE INFORMATION GIVEN AT THE TIME OF ENROLLMENT.

I ACKNOWLEDGE THAT THE CENTER CAN NOT ASSUME RESPONSIBILITY FOR A CHILD WHO WAS NOT SIGNED IN UPON ARRIVAL.

I HEREBY AGREE TO COMPLY WITH THE POLICIES REGARDING FEES, PAYMENT, SCHEDULTING HEALTH, AND OTHER ITEMS SPECIFIED IN THE PARENT HANDBOOK.

GIRAFFE LAUGH WILL MAKE REASONABLE ACCOMMODATIONS FOR ANYONE WITH A KNOWN PHYSICAL OR MENTAL LIMITATION. REQUEST FORMS ARE AVAILABLE IN THE OFFICE AND IT IS MY RESPONSIBILITY TO INFORM THE CENTER OF MY NEED.

SIGNED (PARENT OR GUARDIAN)______DATE:______

TTY: 1 .800 .377 .3529

USDA is an equal opportunity provider and employer

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