Rosalind hills baptist church

Child Development Center

Enrollment Form

Student's Information

School Term

Student's Name

Preffered Name

Grade Level

Date of Birth

Church Affilliation

Elementary School

Primary Family Information

Address

Email Address

Home Phone

Father's Information

Father's Name

Preffered Name

Title

Email Address

Cellphone

Company Name

Business Phone

Extension

Church Affiliation

Address If not the same as the primary

Emergency Contact

Yes No

Allowed to pick up child?

Yes No

Mother's Information

Mother's Name

Preffered Name

Title

Email Address

Cellphone

Company Name

Business Phone

Extension

Church Affiliation

Address If not the same as the primary

Emergency Contact

Yes No

Allowed to pick up child?

Yes No

Step Father's Information

Step Father's Name

Preffered Name

Title

Email Address

Cellphone

Company Name

Business Phone

Extension

Church Affiliation

Address If not the same as the primary

Emergency Contact

Yes No

Allowed to pick up child?

Yes No

Step Mother's Information

Step Mother's Name

Preffered Name

Title

Email Address

Cellphone

Company Name

Business Phone

Extension

Church Affiliation

Address If not the same as the primary

Allowed to pick up child?

Yes No

Emergency Contact

Yes No

Emergency Contacts other than parents

Contact Name

Relation

Home Phone

Business Phone

Cell Phone

Contact Name

Relation

Home Phone

Business Phone

Cell Phone

Contact Name

Relation

Home Phone

Business Phone

Cell Phone

Medical Contacts

Physician

Phone Number

Dentist

Phone Number

Hospital Preference

Carilion Lewis Gale

Insurance

Policy Number

A physical exam is required for a child upon enrollment at RHCDC. Immunization records are to be submitted immediately, and when new immunizations occur or at the request of RHCDC.

Please list any chronic physical problems/pertinent developmental information/special accommodations needed:

Please give any other information or medical history that would be beneficial to us:

Please list any allergies or intolerance to foods, medication, or other substances (wasps, bees, etc):

Please give steps to be taken in an allergic emergency:

We give permission for sunscreen to be applied according to state regulations:

RHCDC agrees to notify the parent/guardian whenever the child becomes ill and the parent/ guardian agrees to arrange for immediate pick-up of child if so requested.

The parent/guardian authorizes RHCDC to obtain immediate medical care for our child. In the event we cannot be reached, we the parent/guardian grant our consent for the hospital and its medical staff to provide my/our child with emergency medical treatment which a physician deems necessary, to include anesthesia. We also understand that our child may be taken to the nearest hospital or medical facility. I/We agree to accept financial responsibility for all expenses incurred

Name of Parent / Guardian

Signature of Parent/Guardian

Date Signed

Pickup Information

Name

Phone

Other

Name

Phone

Other

Name

Phone

Other

Pick Up Authorization (list names of any person who may not pick up your child from RHCDC)

Name

Relationship to child

Name

Relationship to child

Are there any legal/custody issues that we need to be aware of?

What is your approximate pick up time:

What is your approximate drop off time?

Do you authorize use of publicity photos taken without compensation that shows your child’s participation in RHCDC?

Yes No

I consent to the participation of my child in any field trips planned by RHBC CDC for as long as my child is enrolled.

Yes No

* Please provide RHCDC with a copy of your child’s birth certificate as well as a copy of their physical and shot record.

Name of Parent / Guardian

By attaching my signature, I acknowledge that I have entered the correct information and I read, understand, and agree to the policies and procedures stated on this enrollment form.

Date Signed

Rosalind Hills
Baptist Church

Faith, Friends, and Family

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