Update Family and Student Information Update Family and Student Information Contact InformationAre you updating information for more than one child?* YES NO Enrollment (1)*Child's NameChild's BirthdateClassroom (Toddler or Preschool)# of Days per WeekEnrollment (2)Child's NameChild's BirthdateClassroom (Toddler or Preschool)# of Days per WeekFamily Photo(s)*Please upload one or more photos of your family, pets, and close extended family to put in your child's portfolio. We use these photos with your child to help calm and reassure them when they are missing you. Drop files here or Select files Accepted file types: jpg, png, Max. file size: 32 MB, Max. files: 4. Parent or Guardian Name #1* First Last Home Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email #1* Enter Email Confirm Email Phone #1 Personal*Phone #1 Work*Employer #1* Job Title #1 Parent or Guardian #2*Is there a second parent or guardian? YES NO Parent or Guardian Name #2* First Last Email #2* Enter Email Confirm Email Home Address #2 (IF DIFFERENT THAN ADDRESS #1) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone #2 Personal*Phone #2 Work*Employer #2* Job Title #2* Persons Authorized to Pick Up*Who will be bringing and picking up the child(ren) to and from the center each day? Please include yourself and list individuals in order of frequency. You may add up to five individuals, just click on the plus sign at the end of each row to add another row. NameRelationship to ChildContact Phone #Email Typical Drop-Off Time*Please let us know what time your child(ren) will be dropped off each day. We prefer that it is no later than 9:30 (we open at 7:30). Hours : Minutes AM PM AM/PM Typical Pick-Up Time*Please let us know what time your child(ren) will be picked up each day. We prefer that it is no earlier than 3:15. (We close at 5:30. There is a fee of $1/minute for every minute after 5:30 that the child(ren) are not picked up.) Hours : Minutes AM PM AM/PM Emergency Contacts*Please list up to five individuals, just click on the plus sign at the end of each row to add another row. NameRelationship to ChildContact Phone #Email Billing address*Which address should we use for billing? Monthly invoices and receipts are sent by email. Email 1 Email 2 General Health InformationHealth Insurance Company* Subscriber Name* Policy Number* Child(ren)'s Physician or Preferred Provider* Phone # of Provider*Address of Provider Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Emergency Hospital Preference* Dental ProviderWho is your child's dentist? Child's Information (1)Child's Name (1)* First Last Nickname (1) Birth Date (1)* Month Day Year Child's Health History (1)Date of last well baby or child exam: (1)* MM slash DD slash YYYY Exams (1)*Please indicate what health exams your child has had in the last year: Vision Hearing Dental Vision (1)When did this occur and what was the outcome of the vision test?Hearing (1)When did this occur and what was the outcome of the hearing test?Dental (1)When did this occur and what was the outcome of the dental exam?Immunization Record (1)*Create an account on MyIR.net to access your child’s immunization records. This takes about five minutes to complete. Once you have created your account, please download and/or print out the immunization record for each child enrolled in our program and upload the file here.Accepted file types: jpg, gif, pdf, Max. file size: 32 MB.Allergens and Irritants (1)*For allergies of a serious nature that cause reactions involving hives or other potentially severe symptoms requiring the administration of medication or emergency medical response, a full Allergy Reaction Plan & Medication Orders are required from your health care provider.Allergen/IrritantIntoleranceAllergySubstitute (if applicable) Allergies (1)*Are any of the above life threatening? YES NO Allergy Reaction Plan & Medication Orders (1)*Accepted file types: jpg, gif, pdf, Max. file size: 32 MB.Illnesses and Accidents (1)Please list any illnesses (common to chronic) and serious accidents that you child has had and at what age. You can add rows by clicking on the plus sign at the end of each row.Illness or AccidentAge Health Concerns (1)Please describe any other health concerns that our staff should be aware of:Child's Information (2)Child's Name (2)* First Last Nickname (2) Child's Birth Date (2)* Month Day Year Child's Health History (2)Date of last well baby or child exam: (2)* MM slash DD slash YYYY Exams (2)*Please indicate what health exams your child has had in the last year: Vision Hearing Dental Vision (2)When did this occur and what was the outcome of the vision test?Hearing (2)When did this occur and what was the outcome of the hearing test?Dental (2)When did this occur and what was the outcome of the dental exam?HiddenDental ProviderWho is your child's dentist? Immunization Record (2)*Create an account on MyIR.net to access your child’s immunization records. This takes about five minutes to complete. Once you have created your account, please download and/or print out the immunization record for each child enrolled in our program and upload the file here.Accepted file types: jpg, gif, pdf, Max. file size: 32 MB.Allergens and Irritants (2)*For allergies of a serious nature that cause reactions involving hives or other potentially sever symptoms requiring the administration of medication or emergency medical response, a full Allergy Reaction Plan & Medication Orders are required from your health care provider.Allergen/IrritantIntoleranceAllergySubstitute (if applicable) Allergies (2)*Are any of the above life threatening? YES NO Allergy Reaction Plan & Medication Orders (2)*Accepted file types: jpg, gif, pdf, Max. file size: 32 MB.Illnesses and Accidents (2)Please list any illnesses (common to chronic) and serious accidents that you child has had and at what age. You can add rows by clicking on the plus sign at the end of each row.Illness or AccidentAge Health Concerns (2)Please describe any other health concerns that our staff should be aware of: