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DIRECTOR S USE ONLY CHILD S ENROLLMENT RECORD Date enrolled Child s full legal name First Middle Sex Child s preferred name/nickname Address Primary hours child will be in the children s center Days of week child will be in the children s center Who has legal custody Last Birth Date Street Address number apartment street Relationship City State Home Phone Parent s Name Zip Code Cell Phone Place of Employment Address of Employer Telephone The child will be released only to the person s authorized or in the manner authorized in writing by the custodial parent s or legal guardian s. The following person must be someone other than the custodial parent s or legal guardian s and is authorized to remove the child from the facility in case of illness accident or emergency if for some reason the custodial parent s or legal guardian s cannot be reached Name CONTINUED ON PG 2 Child s Physician/Health Resource Telephone Number Hospital Preference Name of Dentist MISCELLANEOUS INFORMATION List all known allergies List all identifying scars birthmarks skin discolorations Special medical or dietary needs of child List any areas of concern My signature below verifies that I give permission to consult the child s physician/health resource listed above in case of emergency if parent/legal guardian cannot be reached. I have received a copy of the Know Your Child s Children s Center brochure and a copy of the children s center discipline policy. I was notified that the snacks/meals served daily are Breakfast AM Snack Lunch PM Snack Dinner I verify that the information on this enrollment form is complete and accurate. DIRECTOR S USE ONLY CHILD S ENROLLMENT RECORD Date enrolled Child s full legal name First Middle Sex Child s preferred name/nickname Address Primary hours child will be in the children s center Days of week child will be in the children s center Who has legal custody Last Birth Date Street Address number apartment street Relationship City State Home Phone Parent s Name Zip Code Cell Phone Place of Employment Address of Employer Telephone The child will be released only to the person s authorized or in the manner authorized in writing by the custodial parent s or legal guardian s. The following person must be someone other than the custodial parent s or legal guardian s and is authorized to remove the child from the facility in case of illness accident or emergency if for some reason the custodial parent s or legal guardian s cannot be reached Name CONTINUED ON PG 2 Child s Physician/Health Resource Telephone Number Hospital Preference Name of Dentist MISCELLANEOUS INFORMATION List all known allergies List all identifying scars birthmarks skin discolorations Special medical or dietary needs of child List any areas of concern My signature below verifies that I give permission to consult the child s physician/health resource listed above in case of emergency if parent/legal guardian cannot be reached* I have received a copy of the Know Your Child s Children s Center brochure and a copy of the children s center discipline policy.

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  • MISCELLANEOUS
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