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Extended Care Application

Find our online registration below.

Child's Information

Name*

Nickname*

Date of Birth*

Sex*

Grade*

Address 1*

City*

State*

ZIP*

Home Phone*

Chronic Physical Problems/Pertinent Developmental Information/Special Accomodations Needed*

Previous Child Day Care Programs and Schools Attended*

If Child Attends this Center and Another School/Program, Give Name of School/Program and Grade*

Parent(s) / Guardian(s)

Your Email*

Father*

Place Employed*

Cell Phone*

Home Address*

Home Phone*

Mother*

Place Employed*

Cell Phone*

Home Address*

Home Phone*

Person(s) or Agency Having Legal Custody of Child*

Home Address*

Home Phone*

Business Address*

Cell Phone*

Emergency Information

Allergies or Intolerance to Food, Medication, etc. and Action to Take in an Emergency*

Child's Physician and Phone Number*

#1 Person to Contact if Parent(s) Cannot Be Reached. Please include Address and Phone Number*

#2 Person to Contact if Parent(s) Cannot Be Reached. Please include Address and phone number*

Person(s) authorized to pick up your child*

Person(s) not authorized to visit or pick up your child*

Appropriate paperwork such as custody papers shall be attached if a parent is not allowed to pick up the child.

NOTE: Section 22.1-4.3 of the Code of Virginia states that unless a court order has been issued to the contrary, the noncustodial parent of a student enrolled in a public school or day care center must be included, upon request of such noncustodial parent, as an emergency contact for events occurring during school or day care activites.

Agreements

1. The child day center agrees to notify the parent(s)/guardian(s) whenever the child becomes ill and the parent(s)/guardian(s) will arrange to have the child picked up as soon as possible if so requested by the center.

2. The parent(s)/guardian(s) authorize the child day center to obtain immediate medical care if any emergency occurs when the parent(s)/guardian(s) cannot be located immediately. **

** If there is an objection to seeking emergency medical care, a statement should be obtained from the parent(s) or guardian(s) that states the objection and the reason for the objection.

3. The parent(s) /guardian(s) agree to inform the center within 24 hours or the next business day after his child or any member of the immediate household has developed a reportable communicable disease as defined by the State Board of Health, except for life threatening diseases which must be reported immediately.