Enrollment Information        
                                                      

Personal Information
Child’s Name                                                   Date of Birth                          M         F         
Father’s Name                                                  Driver’s License #                                          
Address                                                           City, State, Zip                                              
Home Phone                                                   
Father’s Business Place                                                Business Phone                                   
Business Address                                                        Work Hours                                        
Mother’s Name                                                Driver’s License #                                          
Address                                                           City, State, Zip                                              
Home Phone                                                   
Mother’s Business Place                                              Business Phone                                   
Business Address                                                        Work Hours                                        
Person or Persons Authorized To Pick Up Child:
Name                                                               Telephone/Address                                        
Name                                                               Telephone/Address                                        
Name                                                               Telephone/Address                                        
Attendance
Time: From                  To                    Days   M         T          W         Th        F
Person Responsible for tuition                                                                                              
A child who appears ill upon arrival shall not be admitted to BCDC;

1. When a child becomes ill at BCDC, the parents shall be contacted and arrangements made for the child to be picked up immediately.  The determination will be made by the Center;
2. The Center may require a written permission slip before reentry to the center is permitted;
3. At the time of registration the parents should authorize the child’s physician to accept all calls from the child care director for emergency medical care.

Signature of Parent                                                                 Date                                       
Signature of Director                                                 Date                                       

Emergency Authorization Form

Child’s Name                                       Home Phone                                                               
Birth Date                                           Home Address                                                
Weight                         Height                                    
Mother’s Name                                                Father’s Name                                                 
Employed at                                                     Employed at                                                    
Business Phone                                                Business Phone                                               
Insurance Company                                         Last Tetanus Shot                                          
Medications taken on a daily basis                                                                                         
Allergies                                                                                                                                 
Names of friends or relatives who can pick up child in case of emergency
1.                                                                      Phone                          or                                
2.                                                                     Phone                          or                    
3.                                                                      Phone                          or                    
Names of people who cannot pick up child for any reason
1.                                                                                             
2.                                                                                            
Physician/ Dentist to be called in case of emergency
1.                                                                      Phone                          or                    
2.                                                                     Phone                          or                    
Hospital preference                                                               
I hereby grant permission for the director or supervisory staff person to take whatever steps may be necessary to obtain emergency medical care if warranted.  These steps may include:
1.  Attempt to contact a parent or guardian;
2.  Attempt to contact the child’s physician;
3.  Attempt to contact you through any of the persons listed on the emergency form you completed for us.
4.  If we can not contact you or child’s physician, we will do any or all of the following:
            A. call another physician or paramedic;
            B. call an ambulance;
            C. have the child taken to an emergency hospital in the company of a staff member.
5.  The child’s family will pay any expenses under 4 above.