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Child Care Registration Form

This document is a child care registration form for Bayside Kids Camp. It collects contact information for the child's parents/guardians, emergency contacts, health information, insurance details, and consent for emergency medical treatment. Parents must provide the child's name, date of birth, parents' contact details, emergency contacts, health records, insurance coverage, and signed consent for camp staff to authorize medical care for the child if parents cannot be reached.

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CourtneyOwczarek
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121 views3 pages

Child Care Registration Form

This document is a child care registration form for Bayside Kids Camp. It collects contact information for the child's parents/guardians, emergency contacts, health information, insurance details, and consent for emergency medical treatment. Parents must provide the child's name, date of birth, parents' contact details, emergency contacts, health records, insurance coverage, and signed consent for camp staff to authorize medical care for the child if parents cannot be reached.

Uploaded by

CourtneyOwczarek
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Bayside Kids Camp Child Care Registration Form

Childs name Last First Middle Date child entered care Date child left care Child Shirt Size: (For office use) Birthdate Name (Nickname) used

Street address Childs parent/guardian name

City

Zip code

home phone # ( ) City

cell phone# ( ) -

alternative phone # ( ) -

Street address

Zip code

Address where you can be reached while child is in care Childs parent/guardian name

City

Zip code

home phone # ( ) City

cell phone# ( ) -

alternative phone # ( ) Zip code -

Street address

Address where you can be reached while child is in care

City

Zip code

Other than you, who else has permission to pick up your child? In case of an emergency, or other circumstances, I give permission for any of the following individuals to be contacted and my child may be released to any of them. Parent/Guardian signature: --------------------------------------------------------------------------Name Address Telephone number Name: Home: ( ) Relationship: Cell: ( ) Alternative: ( ) Name: Relationship: Home: ( ) Cell: ( ) Alternative: ( Home: ( ) Cell: ( ) Alternative: ( ) ) -

Name: Relationship:

Who does not have permission to pick up your child? If applicable (A copy of supporting court document must be on file)

Name:

Reason:

Name

Reason:

Date of childs last physical exam:

Childs health information Childs health care provider

Telephone number ( ) Zip code

Street address

City

Special health problems? If yes, specify.

Allergies, including drug reactions. If applicable specify

Regular medications? Please specify.

Other important information Yes or no? If yes, specify.

Childs dentists name

Telephone number ( ) City Childs medical insurance coverage Member/policy number Zip code

Street address

Insurance company name

Policy holder name

Employer name

Insurance company name

Member/policy number

Policy holder name

Employer name

Consent to medical care and treatment of minor children I give permission that my child,______________________________________________ may be given first aid/emergency treatment by the child care trained and/or qualified staff at: (Name of Camp)__________________________ at (Address of Camp) ______________________________________________________ Parent/guardian signature Date Parent/guardian signature Date

When I cannot be contacted, I authorize and consent to medical, surgical and hospital care, treatment and procedures to be performed for my child by a licensed physician, health care provider, hospital or aid car attendant when deemed necessary or advisable by the physician or aid car attendant 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. I certify under penalty of perjury under the laws of the State of California that this information is true and correct. Parent/guardian signature Date Parent/guardian signature Date

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