Millbrook Baptist Preschool

MILLBROOK BAPTIST PRESCHOOL

1519 E. Millbrook Road, Raleigh, N.C. 27609-4888

Phone: 919-876-4030

Summer Camp Registration Form 2017

Please complete all pages in pen or type and return to the office.

Please place a check mark in the boxto indicate which session(s) you wish to enroll your child.

Wee Camp
(Must be 1 by 1/2017)
1-2 yrs
T W Th / PreSchool Camp
3-5 yrs
M – F
Session 1 / Water’s Edge / June 5-16
Session 2 / Yummy, Yummy Yellow / June 19-June 30
Session
3 / Everyone’s An Artist / July 10-21
Session 4 / Down On The Farm / July 24 – Aug 4
Session 5 / Come Together With Mother Goose & Dr. Seuss / August 7-18

Child’s Information

First:______/ Middle: ______/ Last: ______
Name Used:______/ Gender: M / F / Birthdate: ______/ Age as of 6/1/17:_____
Previous Preschool Experience:______
How did you hear about our preschool?______
What are your expectations for your child in summer camp?
Please give any information concerning your child which will be helpful in his/her experience in a group setting such as play, eating and sleeping habits, special fears, special likes or dislikes.

Are you interested in receiving information about the ministries of Millbrook Baptist Church? Y/N

Primary Contact Guardian (First person that we will call in an emergency) Relationship to child:______

First:______/ Last: ______/ Name Used: ______
Address: ______
City: ______/ State: ______/ Zip: ______
Home Phone:______/ Cell Phone: ______
Occupation: ______/ Employer:______/ Work Phone: ______
Email: ______

Secondary Contact Guardian (Second person that we will call in an emergency)Relationship to child:______

Other Children in Family

Name: ______/ Age: ______/ Gender: ______
Name: ______/ Age: ______/ Gender: ______
Name: ______/ Age: ______/ Gender: ______
Name: ______/ Age: ______/ Gender: ______

Emergency Contact Information

If neither primary nor secondary guardian can be contacted, please contact (in order):

Name / Relationship / Phone Number / OK for this contact to pick up child? Y/N
1.
2.
3.

Medical Information

Doctor’s Name: ______/ Phone: ______
Dentist’s Name: ______/ Phone: ______
Insurance Provider:______/ Policy Number:______

Information about Your Child

Does your child have any known allergies?
Yes / No / Explain: ______
Treatment Plan for exposure: ______
Does your child have any chronic illnesses/conditions?
Yes / No / Explain: ______
Does your child have any speech or motor delays/problems?
Yes / No / Explain: ______
Do you have any social/emotional concerns about your child?
Yes / No / Explain: ______
Is your child toilet trained?
Yes / No / Explain: ______

I give Millbrook Baptist Preschool my permission to obtain emergency attention for ______.

(Child’s Name)

I prefer my child to be taken to ______hospital, if required by ambulance, and

I understand that I will be billed for this service.

I agree that the operator may authorize the physician of his/her choice to provide emergency care in the event that neither the family physician nor I can be contacted immediately.

______

(Signature of Parent)(Date)

I, as the operator, do agree to provide transportation to an appropriate medical resource in the event of emergency. In an emergency situation a responsible adult will supervise other children in the facility. I will not administer any drug or any medication without specific instructions from the physician or the child’s parent, guardian, or full-time custodian. Provisions will be made for adequate rest and outdoor play.

______

(Signature of Operator)(Date)