Peaceful Beginnings Early Childhood Center Child Registration Form Please complete and submit. Name of Child(ren) * Gender * Male Female Age * Birth Date * MM DD YYYY Name of Child(ren) Gender Male Female Age Birth Date MM DD YYYY Name of Child(ren) Gender Male Female Age Birth Date MM DD YYYY Parents/Guardians * Address * Email Address for Statements * Phone * Mother's Work Place & Address * Work Phone Number * Cell Phone Number * Driver's License Number * Father's Work Place & Address * Work Phone Number * Cell Phone Number * Driver's License Number * Home Church (if not applicable, put N/A) * Baptism * Are/is your child(ren) baptized? Yes No Childcare * Childcare is available from 6:30 AM to 6:00 PM Monday through Friday, ages 6 weeks-13 years. Please check one: Full-Time (5 days per week) Part-Time (M/W/F) Part-Time (T/TR) Authorized Person for Pickup & Emergencies * Please list those people who have permission to pick up your child(ren). Phone * (###) ### #### Authorized Person for Pickup & Emergencies * Phone * (###) ### #### Please list any people who are prohibited from picking up your child(ren): * Please list 2 emergency contacts we may call in the event that you cannot be reached: * Name Phone * (###) ### #### Name * Phone * (###) ### #### Authorization for Treatment * In the event that I cannot be reached in an emergency, I hereby give my permission to the physician selected by the Peaceful Beginnings Director or Director's Designee in the Director's absence to secure and administer treatment, including transportation and hospitalization, for my child(ren) named: * By typing my name in the field below, I am agreeing to the following statement: I understand that my child(ren) will be under proper supervision, and that all reasonable caution will be taken by those in charge of the program in order to prevent injuries. However, I will hold responsible neither the early childhood center, its personnel, nor Peace Lutheran Church in case of an accident. Medication Competency Statement I understand that by typing my name in the field below, I am agreeing to the following statement: I have determined PBECC Directors and Staff are competent to give or apply medication to my child(ren) as long as a signed Medication Form is on file. Health and Emergency Information * Should my child need local hospitalization, I prefer the following hospital: Name of Family Physician * Phone * (###) ### #### Name of Family Dentist * Phone * (###) ### #### Health Insurance Carrier * Please list any chronic or recurring illnesses, medical conditions, etc. * Does your child take any medications that will need to be administered while at Peaceful Beginnings? If yes, what medications, what dosage, and for what medical reason? * Please complete a medication form so we can record the time and dosage for each medication. Please list any dietary restrictions: * Please list any known allergies/reactions: * By typing my name below, I am agreeing to the statement: This health history is correct to the best of my knowledge, and the person herein described has permission to engage in all prescribed activities except as noted above. * I give permission for Peaceful Beginnings to transport my child(ren) on field trips. * Yes No My child(ren)'s picture may be used for Peaceful Beginning's promotion and publicity efforts. * Yes No By typing my name below, I am agreeing to the following statement: I have received the DHHS Parent Information Brochure. * Peaceful Beginnings closes only when absolutely necessary due to inclement weather. As such, Peaceful Beginnings may be open when classes for District 145 schools have been cancelled due to weather. Please indicate whether or not you wish your child(ren) to attend Peaceful Beginnings on inclement weather days. If your child is scheduled to be at Peaceful Beginnings, but does not attend, you will still have the same weekly charge. * Yes, my child(ren) will attend Peaceful Beginnings on District 145 "Snow Days" No, my child(ren) will not attend Peaceful Beginnings on District 145 "Snow Days" Tuition Rates are attached to each form based on what room your child is in. By typing my name below, I acknowledge that I have reviewed the Tuition, Fees and Attendance Policies, and I have been given and have reviewed PBECC's Parent Handbook. * Registration Fees - $100 due every August for Early Childhood Side / $50 due every August for School Age Side The more we know about your child(ren), the better we can serve them. Please provide us with the following information. If you wish not to share any information, please indicate as such. Whom does the child live with and what is their relationship to the child (siblings, parents, etc.)? * Child's parents are: * Married Single Divorced Widowed If divorced or separated, who has custody of the child and whom does the child live with the majority of the time? * Is your child adopted or in the custody of someone other than their biological parents? If so, is the child aware of the situation? * Special Interests: * Does your child prefer to play alone or in groups? * Does your child have any special or strong fears? Please explain. * How would you describe your child's personality? * Do you have any concerns in your child's development? * Is your child fully toilet-trained? * If not, what are their needs? What do you hope your child will gain from our program? * Does your child have any special needs? * Are there any special modifications/considerations to the curriculum or environment needed for your child? * Is there anything else you would like us to know about your child? * I learned about PBECC from: * Word-of-mouth Peaceful Beginnings Website Peace Lutheran Church Website Homepages Ad July 4th Parade Ad in the news (Waverly Newspaper) Sign along Amberly Road Other Thank you for submitting! A staff member will be in touch soon.
