Printable Daycare Form – Fill Out and Use This PDF

WESTBROOK CHRISTIAN SCHOOL

100 Westminster Drive

Rainbow City, AL 35906

(256)442-7457

www.westbrookchristian.org

DAYCARE REGISTRATION FORM

(3K & 4K)

============================================================================================

CHILD’S NAME:________________________________________________________________

PARENT(S):___________________________________________________________________

NAME CHILD GOES BY:______________________________ MALE FEMALE

(Circle one)

CHILD’S HOME ADDRESS:_______________________________________________________

Street Address/P.O. Box/Apartment Number

_______________________________________________________

City/State/Zip Code

TELEPHONE: (_____)________________________ SOCIAL SECURITY #:_______________

AGE OF CHILD:__________________________ BIRTHDAY: _________________________

MOTHER’S NAME:______________________________________________________________

HOME ADDRESS:______________________________________________________________

Street Address/P.O.Box/Apartment Number

______________________________________________________________

City/State/Zip Code

MOTHER’S OCCUPATION:______________________________________________________

TELEPHONE NUMBERS: Home: (_____)______________________________________

Work: (_____)______________Ext._________ Cell: (_____)__________________________

FATHER’S NAME:______________________________________________________________

HOME ADDRESS:______________________________________________________________

Street Address/P.O. Box/Apartment Number

______________________________________________________________

City/State/Zip Code

FATHER’S OCCUPATION:______________________________________________________

TELEPHONE NUMBERS: Home: (_____)______________________________________

Work: (_____)______________Ext._________ Cell: (_____)__________________________

FAMILY

Give names and ages of your child’s siblings:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

If parents are separated, who has custody of the child? ________________________________

A copy of the most recently issued Court Order providing custody status must be on file with the school.

List persons approved to call for child (Child will not be released to others without specific permission from parents.):________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

MEDICAL

NAME OF CHILD’S PHYSICIAN:___________________________________________________

PHYSICIAN’S TELEPHONE NUMBER: (_____)_______________________________________

Persons to be called in case of emergency if parents are unavailable:

NAME:_______________________________________________________________________

RELATIONSHIP:________________________ TELEPHONE: (_____)__________________

NAME:_______________________________________________________________________

RELATIONSHIP:________________________ TELEPHONE: (_____)__________________

Should my child, _____________________________________, become ill or suffer an accident

of any nature while in the care of Westbrook Christian School Daycare, Rainbow City, Alabama, the Preschool Director shall undertake to contact me immediately. In the event she is unable to reach me immediately, she will attempt to reach one of the above listed persons. Should this be impossible, the Director shall be authorized to secure and consent to such medical attention, treatment, and services for my child if given by me in person. I agree to assume the responsibility for payment of all medical costs incurred and not covered by the insurance.

Date:____________________ Parent(s) Signature:___________________________________

____________________________________

Check any of the following your child has had:

_____Other____________________________________________________________________

What allergies does your child have? _______________________________________________

List other medical information that you feel might help us:________________________________

_____________________________________________________________________________

SOCIAL INFORMATION

Is this your child’s first separation from home? _______________________________________

Has your child had any kind of group experience? Describe:_____________________________

_____________________________________________________________________________

Does your child make new friends easily? ___________________________________________

Is your child toilet trained? ________________________________________________________

What special words does your child use to tell you he/she needs to urinate or have a bowel movement? __________________________________________________________________

What time does your child get up in the morning? ____________________________________

What time does your child go to bed at night? ________________________________________

Is your child accustomed to taking an afternoon nap? _______ For how long? ______________

Does your child have any special nap or bedtime routine? ______________________________

_____________________________________________________________________________

What time does your child usually have: Breakfast________ Lunch_________ Dinner________

Is your child accustomed to having between meal time snacks? __________________________

Does your child need any help feeding himself/herself? ________________________________

What fears does he/she have (such as animals, storms, etc.)?____________________________

_____________________________________________________________________________

How do you handle these fears? __________________________________________________

Other comments and special instructions: ___________________________________________

_____________________________________________________________________________

RELIGIOUS AFFILIATION

What church do you attend?_______________________________________________________

Do you attend: Regularly_______ Occasionally_______ Seldom_______

Is your child enrolled in Sunday School? ____________________________________________

If not a church member, give a church preference: ____________________________________

WESTBROOK CHRISTIAN SCHOOL

Child’s Medical Report – Daycare

CHILD’S NAME:__________________________________ DATE OF BIRTH:_______________

PARENT OR GUARDIAN’S NAME:_________________________________________________

HOME ADDRESS:______________________________________________________________

Street Address/P.O.Box/Apartment Number

______________________________________________________________

City/State/Zip Code

HOME TELEPHONE: (_____)_____________________________________________________

Attach Certificate of Immunizations (blue slip) for children age 4 years and older. If blue slip is not available or if child is 3 years of age and under, complete the section below.

History of Allergies:_____________________________________________________________

_____________________________________________________________________________

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I examined this child on this date _________________. I find him/her to be in good physical condition, free of contagious

and infectious diseases, and capable of participating in daycare activities, except as noted below.

DATE:________________ PHYSICIAN’S SIGNATURE:________________________________

STATE OF ALABAMA

AFFIDAVIT FOR PARENT/GUARDIAN

COUNTY OF ETOWAH

Before me, a Notary Public in and for said State and County, appeared

________________________________________________________________

and is known to me, after being duly sworn or affirmed, says as follows:

The affiant is the parent or legal guardian of the minor child/children

_____________________________________: that affiant has been notified by

Sandra Handley, a representative of Westbrook Christian School, that said church or school has filed notice and is exempt under law from regulation by The Department of Human Resources.

____________________________________ parent/legal guardian sworn,

or affirmed to and subscribed before me this _______ day of _______________,

20_______.

________________________________

NOTARY PUBLIC

My Commission Expires:____________

Westbrook Christian School

After-school Care Contract

5K – 6th

After-school care for 5K – 6th grade is set up on a contract system. Due to limited space, availability will be based on a first-come, first-serve basis. Therefore, the sooner we receive your completed contract—the better chance you will have of obtaining a place for your child(ren).

Please complete and return the following:

Child’s Name: ____________________________________________________

If enrolling more than one child, you may use one contract for all of your children as long as they are enrolled for the same time periods. If not, please complete a separate contract for each child.

Circle the days your child will need after-school care:

Circle the hours your child will need after-school care:

Cost is $3.00 per hour. After choosing the contract plan, bookkeeping will provide you with a list of cost per month based on the school calendar.

You are choosing between three contracts, which are set up to allow for pick-up any time during the time frame set by the selected contract. Your cost is based on the particular contract you select. If you are late picking up your child(ren) more than once, you will automatically be switched to the next contract.

Adjustments to your payments will be made at that time. There is a late fee of

$5.00 for every 2 minutes past 5:30 p.m.

I agree to pay Westbrook Christian School with post-dated checks (dated August, 2010 – May, 2011) for the hours I have enrolled my child(ren) in after-school care. These charges will apply even in the event my child is unable to attend.

Parent’s signature: __________________________________ Date: ________