General Infomation
Parent or Guardian Email Address*
Child's Name*
First Last
Date Form Filled Out*
MM slash DD slash YYYY
Parent or Guardian Signature*
This letter is to verify that I have received a copy of and agree to the policies and procedures set forth in the Smoke Rise Baptist Child Care and PreSchool Parent Handbook

Child's Information
Child's Name*
First Last
Name Child Is Known By
First
Child's Birthdate*
MM slash DD slash YYYY
Child's Home Address*
Street Address City State / Province / Region ZIP / Postal Code
Parent / Guardian (Primary)
Name of Parent/Guardian*
First Last
Phone Number*
Relationship To Child*
Is Your Address The Same As The Child's?*
Address of Parent(s)/Guardian(s)*
Street Address City State ZIP Code
Parent / Guardian
Name of Parent/Guardian
First Last
Phone Number
Relationship To Child
Is Your Address The Same As The Child's?
Address of Parent(s)/Guardian(s)
Street Address City State ZIP Code
Instructions Regarding How Parent(s)/Guardian(s) May Be Reached In An Emergency
Emergency Contact if Parent(s)/Gauardian(s) cannot be reached
Primary Contact
Name*
First Last
Relationship to child*
Telephone number*
Secondary Contact
Name
First Last
Relationship to child
Telephone number
Medical Information
Name of Child's Doctor
First Last
Doctor's telephone number
Signature
Emergency Authorization: I give permission for the child care facility to obtain emergency medical treatment, including emergency transportation, for my child if I cannot be reached immediately. I agree to be responsible for any emergency medical expenses incurred. (If parent/guardian refuses to sign, instructions must be attached stating what procedure the facility is to follow in an emergency.)
Date
MM slash DD slash YYYY

Describe any special needs or instructions below
Person(s) child may be released to:
Option 1
Name
First Last
Relationship to child
Telephone number
Option 2
Name
First Last
Relationship to child
Telephone number
Signature of parent/guardian
I understand that the Department of Human Resources does not inspect activities away from the child care facility (home or center). The license of the child care facility assumes full responsibility for such activities.
I give permission for my child to participate in:
I give permission for my child to participate in:*
- Select All
- Activities away from the facility
- Transportation provided by facility
- Swimming/wading activities provided by facility
Signature*
Above selections not valid without signature of child's parent/guardian

Signature*
I have received a copy of and agree to the policies and procedures set forth in the Smoke Rise Baptist Child Care Center Parent Handbook.
Parent's Name*
First Last
Date Signed*
MM slash DD slash YYYY

Child's Medical Record
Child's Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Mother's Name
First Last
Home Number
Cell Number
Work Number
Father's Name
First Last
Home Number
Cell Number
Work Number
Allergies/Reactions:
Chronic Illness:
Additional Information:
Signature*
In addition to medical records, a Certificate of Immunization (ADPH-F-IMM-50) is required for each child two months to five years of age and for five-year-olds who are not enrolled in public school.
Date Signed
MM slash DD slash YYYY
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.

Registration

General Infomation