Community Building
Children's Center Registration

New Student and Family Registration

Enrollment Information

Child's First Name

Child's Last Name

Child's Date of Birth

Classroom

# of Days per Week

Drop-Off Time

Pick-Up Time

Parent/Guardian Information

Address Line 1

Address Line 2

City

State

Zip Code

Parent/Guardian Name #1 (First, Last)

Parent/Guardian #1 Phone (Personal)

Parent/Guardian #1 Employer

Parent/Guardian #1 Phone (Work)

Parent/Guardian #1 Email Address

Parent/Guardian Name #2 (First, Last)

Parent/Guardian #2 Phone (Personal)

Parent/Guardian #2 Employer

Approved Pick-Up Information

Approved Pick-Up #1 Name (First, Last)

Approved Pick-Up #1 Phone

Approved Pick-Up #1 Relationship to the Child

Approved Pick-Up #2 Name (First, Last)

Approved Pick-Up #2 Phone

Approved Pick-Up #2 Relationship to the Child

Approved Pick-Up #3 Name (First, Last)

Approved Pick-Up #3 Phone

Approved Pick-Up #3 Relationship to the Child

Emergency Contact Information

Emergency Contact #1 Name (First, Last)

Emergency Contact #1 Phone

Emergency Contact #1 Relationship to the Child

Emergency Contact #2 Name (First, Last)

Emergency Contact #2 Phone

Emergency Contact #2 Relationship to the Child

Approved Pick-Up #3 Name (First, Last)

Approved Pick-Up #3 Phone

Approved Pick-Up #3 Relationship to the Child

Medical Information

Physician Name

Physician Phone

Insurance Provider

Policy Number

Name of Policy Holder

Dentist Name

Dentist Phone

Preferred Hospital

Date of Last Well Child Exam

Date of Last Dental Exam

Child Health Concerns

Child Immunization Record

Allergy/Prescription Information

Allergen

Reaction

Allergy or Intolerance

Life Threatening?

Allergen

Reaction

Allergy or Intolerance

Life Threatening?

Allergen

Reaction

Allergy or Intolerance

Life Threatening?

Medication

Reason Prescribed

Medication

Reason Prescribed

Child/Family Information

Family

Traditions

Fears/Dislikes

Comfort

Temperament

Food Preferences

Family Photo

Policies and Authorizations

Community Building Children's Center has my permission to give my phone number and email to other enrolled families.

Community Building Children's Center has my permission to take photographs/video of my child for documentation, assessment, and training purposes.

Community Building Children's Center has my permission to take my child on walks.

Family Handbook: I have read the CBCC Family Handbook.

Disaster Handbook: I have read the disaster handbook and understand Community Building Children's Center's protocols in the event of an emergency situation.

Treatment Authorization: I hereby give my permission that my child, named above on this form, may be given emergency treatment to include first aid and CPR by a qualified child care provider at Community Building Children's Center. When I cannot be contacted, I authorize and consent to medical and hospital care, treatment, and procedures for surgery, to be performed for my child by a licensed physician, health care provider, hospital, or EMT when deemed necessary or advisable to safeguard my child's health. I waive my right of informed consent to such treatment. I also give my permission for my child to be transported by ambulance or aid car to an emergency center for treatment.

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Community Building
Children's Center Registration

New Student and Family Registration

PARTNERS

Contact

LOCATION

Community Building Children's Center Registration

New Student and Family Registration

PARTNERS

Contact

LOCATION

Community Building
Children's Center Registration