Fillable Printable Child Registration Form - The Children's Nest Preschool and Daycare

Child Registration Form - The Children's Nest Preschool and Daycare

The Children’s Nest Preschool and Daycare

1155 Draper Road SW, Blacksburg, VA 24060

Child Registration Form

Child’s Name ___________________________ Nickname_____________ Sex ____ Birthdate ___________

Address _______________________________________________________ Home Phone _________________

Parents/Guardians:

Father’s Name __________________________________________________ Cell Phone _________________

Place of Employment _____________________________________________ Work Phone ________________

Home Address and Phone (if different from child) ____________________________________________________

Mother’s Name __________________________________________________ Cell Phone _________________

Place of Employment _____________________________________________ Work Phone ________________

Home Address and Phone (if different from child) ____________________________________________________

Person(s) or Agency having legal custody of child ___________________________________________________

Home Address ___________________________________________ Home Phone ______________________

Business Address _________________________________________ Business Phone ____________________

Emergency Information for Child:

Name of Child’s Physician __________________________________________ Phone ____________________

Allergies or intolerance to food medication, etc. ______________________________________________________

Please list any other medical issues (including, but not limited to, any developmental delays, chronic conditions, and

any other physical, emotional or cognitive issues) ____________________________________________________

Local Emergency Contacts (if parents/guardians cannot be reached)

Name Address Phone Relationship to Child

1. _________________________________________________________________________________________

2. _________________________________________________________________________________________

Person(s) authorized to pick up child ______________________________________________________________

Person(s) NOT authorized to visit or pick up child ____________________________________________________

If child attends this center and another school:

Name of School ___________________________________ Phone ______________________ Grade _____

Parent Agreements (please initial)

1. I, the parent/guardian, authorize The Children’s Nest Preschool and Daycare to take my child on field trips

when feasible. Permission slips will be distributed for parent/guardian to sign before all field trips. _____

2. The Children’s Nest Preschool and Daycare agrees to notify the parent/guardian when the child becomes ill

and the parent/guardian agrees to pick the child up as soon as possible thereafter. ______

3. I, the parent/guardian, authorize The Children’s Nest Preschool and Daycare to obtain immediate medical

care if an emergency occurs and I cannot be reached. ______

4. I, the parent/guardians, authorize The Children’s Nest to take photographs of my child during daily activities

and to post the pictures in the classroom. ______

5. I, the parent/guardian, authorize The Children’s Nest and/or their website developer to take pictures of my

child during daily activities and post them on The Children’s Nest Website. No names will be used. ______

Signature: ___________________________________________ Date _______________________________

Date Admitted ________________________________________ Date Withdrawn ______________________

Administrator/Director Signature __________________________ Date _______________________________

Please fill out this form, sign it, scan it, and email the file to info@ChildrensNest.com or mail it via postal mail or bring it to the office.