Dear Parents,
Thank you for choosing Kid Garden for your
child. We look forward to being a big family together.
We are subject to many state regulations. For
your child's well-being and safety and our compliance, please use checklist so enrollment is complete:
___ Emergency Authorization
___ Intake
___ Medical Information
___ Medical Record (to be completed by a
physician)
___ Copy of Immunization Record
___ Signature Page (that you've received and
read the Kid Garden Policies and Procedures and authorizations)
_____ $100 Check to Jean Borne
Thank you,
Jean Borne
Director
Signature
Page
We verify that we have received and read the Kid Garden Policies and Procedures.
We authorize my child to participate in field trips and excursions.
We authorize my child to view age-appropriate educationally thematic media.
_____________________________________________________________
Signed
Dated
_______________________________________________________________________________________
Signed
Dated
Emergency Authorization:
I hereby grant permission for the director or
supervisory staff person to take whatever steps may be necessary to obtain
emergency medical care if warranted. These steps may include:
1. Attempt to contact a parent or guardian.
2. Attempt to contact the child’s physician.
3. Attempt to contact you through any of the
persons listed on the emergency information form you completed for us.
4. If we cannot contact you or your child’s
physician, we will do any or all of the following:
(a) Call another physician or paramedic, (b)
call an ambulance, (c) have the child taken to an emergency hospital in the
company of a staff member.
The child's family will pay any expenses under
4 above.
_________________________________________
_______________
Signature of Parent or Guardian Dated
Photo/ Video/ Media
Release Form: Minor Child
Date:
___________________, 20________
I,
______________________________________ the undersigned, do hereby grant
permission to Kid Garden to use the image of my minor child, ______________________________
for educational purposes. Such uses includes the display, distribution,
publication, transmission, or otherwise use of photographs, images, and/or
video taken of my child for use in materials that include, but may not be
limited to, printed materials such as brochures and newsletters, videos, and
digital images such as those used on the Kid Garden web site.
I agree that these
images may be used by Kid Garden for a variety of purposes and that these
images may be used without further notifying me. I do understand that the child’s name will not be used in conjunction with any of these images. This agreement is good until I rescind
it in writing.
Child’s Name:__________________________________________________
(please
print)
Parent’s Name:
___________________________________________
(please sign)
KID GARDEN
Child Intake Record
School Year _____________ or Summer Camp
Session ____________
Date Completed: ________________ Days per
week:______________
Date Admitted: ___________________
Child’s Name
_____________________________________________________________
Last
First Middle
DOB______________
Child’s Home Address____________________________________________________
_____________________________________________________________
City
State
Zip
PO Box _________ Home Phone _______________
Cell______________
MOTHER:
____________________________________________________
Name
_________________________________________________________________
Home address
_________________________________________________________________
City, ST, Zip
_________________________________________________________________
Phone Date
of Birth
_________________________________________________________________
Occupation
_________________________________________________________________
Business address
_________________________________________________________________
City, ST, Zip
_________________________________________________________________
Business phone #
_________________________________________________________________
email
FATHER:
_____________________________________________________
Name
__________________________________________________________________
Home address
__________________________________________________________________
City, ST, Zip
__________________________________________________________________
Phone Date
of Birth
__________________________________________________________________
Occupation
__________________________________________________________________
Business address
___________________________________________________________________
City, ST, Zip
____________________________________________________________________
Business phone #
____________________________________________________________________
email
BROTHERS
& SISTERS or OTHERS LIVING IN THE HOME:
NAME:____________________________________________
AGE:_______
NAME:____________________________________________
AGE:_______
NAME:____________________________________________
AGE:_______
Special instructions as to how the parents or
guardians can be reached during the hours the child is at the center:
_____________________________________________________________
Local Contacts (please list two) in the event
parents cannot be reached:
Name ______________________________________Phone_____________
Address_______________________________________________________
Name ______________________________________Phone_____________
Address_______________________________________________________
Names, addresses, phone numbers, and
relationship of persons permitted to pick-up child at school (other than
parents):
Names, addresses, and phone numbers of persons
NOT permitted to pick-up or have contact with child
Has your child had experience in preschool,
school or day care?
YES NO
If YES, list locations and dates
_____________________________________________________________
_____________________________________________________________
MEDICAL INFORMATION:
Child’s Physician_______________________________________________
Address _______________________________________________
Phone_________________________
Child’s
Dentist _________________________________________________
Address_________________________________________________
Phone_____________
Is your child covered by a health or medical
insurance plan? YES NO
If yes, list insurer and number
___________________________________________
What illness, if any, has your child had in the
last year?
Type of illness
_____________________________Treatment__________________
Type of illness
_____________________________Treatment__________________
(if more, please list on another sheet of
paper)
Has your child had any serious injuries? If so,
what and when?
_____________________________________________________________
_____________________________________________________________
Does your child have any chronic or
handicapping problems? YES NO
If so, what?
Does your child have any food or environmental
allergies? YES NO
If so, what?
Have you sought professional advice for other
issues involving your child? YES
NO
If you answered yes to any above, attach
appropriate documents that give instructions for the care of any existing or
suspected conditions so we may best serve your child.
I authorize Kid Garden to seek emergency
medical care if necessary.
_______________________________________________________
Signed Dated
ADDITIONAL INFORMATION:
Second Language (if applicable _____________________________________________________________
Play Habits
_____________________________________________________________
Eating Behavior
_____________________________________________________________
Happiest when _____________________________________________________________
Special Interests
_____________________________________________________________
Family’s Special Interests
_____________________________________________________________
Sleeps well?
_____________________________________________________________
Fears
_____________________________________________________________
Allergies
_____________________________________________________________
Other Info
_____________________________________________________________
Please copy, paste, and print out this and the next health form to be filled out by
your doctor:
KID GARDEN
MEDICAL RECORDS
SY10-11
Dear Parents,
Please print off the
next two pages and take to your doctor for a signature.
For your protection,
the Colorado Department of Human Services requires an IMMUNIZATION RECORD and
ANNUAL PHYSICAL EXAMINATION for all students who attend licensed early
childhood programs. Take this form (substitute forms are acceptable) to your
family physician. If you do not have a family doctor and/or are not able to pay
for your child’s medical needs, you may contact Chaffee County Nursing Service
(539-4510) for referral information.
Remember to bring
these completed forms (or a substitute) and your child’s immunization record to
us.
Thank you for your
cooperation.
CHILD’S NAME
____________________________________DOB_________SEX: M F
CHILD’S HOME ADDRESS
_________________________________________PHONE____________
1. If vision and/or
hearing are abnormal, please describe type of problem and recommended
treatment.
2. If any identified
allergies are present, please describe type of allergy and recommended
treatment.
3. If medical
history indicated previous surgical procedures, major accidents, or illnesses,
please describe any continuing concerns:
4. If significant
handicapping or developmental problems are present, please describe:
I have found the
above named child, upon examination, to be in good health and under no unusual
activity restrictions that would limit his or her participation in normal
school activities.
_____________________________________________________________
Signature of
Physician/ Health Nurse Date
Please copy, paste, and print out this health form to be filled out by your doctor.
