Covenant Child Care Registration Form

 

CHILD’S INFORMATION

 

Child’s Full Name: ____________________­­­­­­________________ Birth Date: _____/_____/_____

Address: _____________________________________________ Home Phone: ________________

City: _____________________________ State: _________PC/Zip Code: ________________

Nickname: _______________________________

 

PARENT/GUARDIAN INFORMATION

 

Mother’s Full Name: _________________________________ Home Phone: __________________

Address: __________________________________________________________________________

City: _____________________________ State: _________PC/Zip Code: ________________

Occupation: _____________________________ Work Phone: ____________________ext._______

Name of Employer________________________ Pager or Cellular Phone: ____________________

Business Address: __________________________________ City: ___________________________

Work Hours: ____________________________ Driver’s License # __________________________

 

Father’s Full Name: _________________________________ Home Phone: __________________

Address: __________________________________________________________________________

City: _____________________________ State: _________PC/Zip Code: ________________

Occupation: _____________________________ Work Phone: ____________________ext._______

Name of Employer________________________ Pager or Cellular Phone: ____________________

Business Address: __________________________________ City: ___________________________

Work Hours: ____________________________ Driver’s License # __________________________

 

Parent/Guardian with legal custody _________________________________________________
Parents are: Married ___ Living Together___ Divorced ___ Separated ___ Widowed ___ Single ___

Other Household Members:

Names: _________________________________ Ages: _________ Relationships ________________
Names: _________________________________ Ages: _________ Relationships ________________
Names: _________________________________ Ages: _________ Relationships ________________

 

 

 

 

CHILD PICK-UP INFORMATION

 

Please list below the people who have *Permission* to pick up your child.

*Note:  Anyone picking up your child must have picture ID.

 

Name: __________________________ Phone: _________________ Relationship: __________

Name: __________________________ Phone: _________________ Relationship: __________ Name: __________________________ Phone: _________________ Relationship: __________

 

Please list those persons who *Do Not Have Permission* to pick up your child.

Please explain the reason below or talk to your caregiver so she is aware of the situation.

 

Name: __________________________ Phone: _________________ Relationship: __________

Name: __________________________ Phone: _________________ Relationship: __________

 

Reason person is not allowed to pick up your child:

Name: __________________________

Reason: ___________________________________________________________________________

 

Name: __________________________

Reason: ___________________________________________________________________________

 

EMERGENCY CONTACTS

Primary Emergency Contact (other than parents or guardian)

Name: ________________________________________________

Home Phone: _______________________________ Work Phone: ____________________________

Relationship to Child: ________________________________________________________________

Address: ___________________________________________________________________________

 

Secondary Emergency Contact (other than parents or guardian) Name: ________________________________________________

Home Phone: _______________________________ Work Phone: ____________________________

Relationship to Child: ________________________________________________________________

Address: ___________________________________________________________________________

 

Any Special Instructions on how to reach parents: __________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________

 

EMERGENCY INFORMATION

1. Child’s Physician: ________________________________ Phone: ___________________________

2. Preferred Hospital: _______________________________ Phone: ___________________________

3. Child’s Dentist: __________________________________ Phone: ___________________________

3. Insurance Company: ______________________________ Policy #: _________________________

4. Regular Medications: _______________________________________________________________

5. Blood Type: ______________________________________________________________________

6. Medicine allergic to: _______________________________________________________________

7. Food Allergies: ___________________________________________________________________

8. Any other Allergies: _______________________________________________________________

9. Immunization Record:  Date of Last Immunization: _______________________________________

10. Any special health conditions: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

11.  Child has had:                                                                 Child suffers from:

            [  ] Measles                                                                  [  ] Headaches

            [  ] German Measles                                                     [  ] Earaches

            [  ] Chicken Pox                                                           [  ] Sore Throat

            [  ] Mumps                                                                   [  ] Stomach Aches

            [  ] Whopping Cough                                                    [  ] Flu / Colds

            [  ] Other _____________                                           [  ] Other _____________

 

Child # 1

 

IMMUNIZATION RECORD

 

DPT     1. ___/___/___   2. ___/___/___   3. ___/___/___   4. ___/___/___   5. ___/___/___

Polio    1. ___/___/___   2. ___/___/___   3. ___/___/___    4. ___/___/___   5. ___/___/___ 

MMR        ___/___/___           Measles     ___/___/___     Mumps   ___/___/___

Rubella     ___/___/___    TB     ___/___/___    HIV     ___/___/___     HIB     ___/___/___

 

 

 

Child # 2

IMMUNIZATION RECORD

 

DPT     1. ___/___/___   2. ___/___/___   3. ___/___/___   4. ___/___/___   5. ___/___/___

Polio    1. ___/___/___   2. ___/___/___   3. ___/___/___    4. ___/___/___   5. ___/___/___ 

MMR        ___/___/___           Measles     ___/___/___     Mumps   ___/___/___

Rubella     ___/___/___    TB     ___/___/___    HIV     ___/___/___     HIB     ___/___/___

 

 

OTHER IMPORTANT INFORMATION/PROVISIONS

 

Child will need special provisions such as:

 

 

[  ]        Extra curricular activity [  ] Yes [  ] No

If yes, please give details: (what activity, when, if transportation is required, specific arrangements to attend with other family members/friends, etc.)

            ____________________________________________________________________________

            ____________________________________________________________________________

 

[  ]        Other provisions we should be aware of: ___________________________________________

            ____________________________________________________________________________

            ____________________________________________________________________________

 

Do you have any outstanding concerns? _________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________