TemplateOperationsWord Document

Paquete de Inscripcion

Un conjunto completo de formularios de inscripcion que incluye registro, contactos de emergencia, informacion medica, personas autorizadas para recoger y autorizacion de medios para nuevas familias.

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Form 1.Child Information & Registration

Child's Full Legal Name

First, Middle, Last

Preferred Name/Nickname

Date of Birth

MM / DD / YYYY

Gender

Home Address

Street, City, State, ZIP

Primary Language Spoken at Home

Ethnicity

Optional, for CACFP reporting if applicable

Child's Physician

Physician Name

Office Address

Phone Number

(___) ___-____

Child's Dentist

Dentist Name

Phone Number

(___) ___-____

Health & Medical

Previous Childcare Experience

Center name, dates attended

Allergies (food, environmental, medication)

List all known allergies

Medical Conditions

Asthma, seizures, diabetes, other

Current Medications

Name, dosage, frequency

Special Dietary Needs

Developmental Concerns or Accommodations Needed

Enrollment Details

Program Type

Full-time / Part-time / Before-After School

Requested Start Date

MM / DD / YYYY

Form 2.Parent/Guardian Information

Complete for each parent or legal guardian.

Parent/Guardian 1

Full Name

Relationship to Child

Mother, Father, Legal Guardian, etc.

Home Address

If different from child's address

Cell Phone

(___) ___-____

Work Phone

(___) ___-____

Email Address

Employer Name & Address

Work Hours

Parent/Guardian 2

Full Name

Relationship to Child

Mother, Father, Legal Guardian, etc.

Home Address

If different from child's address

Cell Phone

(___) ___-____

Work Phone

(___) ___-____

Email Address

Employer Name & Address

Work Hours

Custody Status

Marital/Custody Status

Married / Separated / Divorced / Single

Custody Documentation on File?

Yes / No (attach if applicable)

Form 3.Emergency Contact & Authorization

List a minimum of 3 emergency contacts beyond parents/guardians.

Full Name	Relationship to Child	Cell Phone	Home Phone	Work Phone

I authorize the persons listed above to pick up my child in the event I cannot be reached.

Photo ID will be verified for all pickups by emergency contacts.

In a life-threatening emergency, the center will call 911 and transport the child to the nearest hospital if a parent/guardian cannot be reached.

Form 4.Authorized Pickup List

Only persons listed below, with valid photo ID, may pick up your child. List a minimum of 2 authorized persons.

Full Name	Relationship to Child	Phone Number	Photo ID Type & Number

Only persons listed on this form, with valid photo ID, may pick up my child. I will notify the center in writing of any changes.

If someone not on the list arrives, the child will NOT be released until the parent confirms by phone AND the person presents photo ID.

Form 5.Medical Information & Action Plan

Known Allergies

List each allergy with severity and response.

Allergy Type	Specific Allergen	Severity (Mild/Moderate/Severe)	Response/Treatment

Medical Conditions Requiring Action Plans

Complete a separate section for each condition. Physician signature required.

Asthma

Triggers:

Medication name and dosage:

When to administer:

When to call 911:

Physician Signature & Date

Seizures

Type of seizures:

Typical duration:

Medication name and dosage:

When to call 911:

Physician Signature & Date

Severe Allergies/Anaphylaxis

Triggers:

Epinephrine auto-injector location and instructions:

When to call 911:

Physician Signature & Date

Diabetes

Blood sugar monitoring schedule:

Insulin administration instructions:

Signs of hypoglycemia:

Signs of hyperglycemia:

Physician Signature & Date

Other Condition

Condition name:

Symptoms to watch for:

Treatment/response:

When to call 911:

Physician Signature & Date

Immunization Record

Attach current immunization record. Check each vaccine on file.

DTaP (Diphtheria, Tetanus, Pertussis)
IPV (Polio)
MMR (Measles, Mumps, Rubella)
Hib (Haemophilus influenzae type b)
Hepatitis B
Varicella (Chickenpox)
PCV13 (Pneumococcal)
Hepatitis A
Influenza (if required by state)
COVID-19 (if required by state)

Physician signature required for all medical action plans.

Religious or medical exemption documentation must be attached if applicable.

Form 6.Medication Administration Authorization

Complete for each medication. Medication must be in original labeled container. Prescription label must match this form. Over-the-counter medications require a physician note in most states.

Standing Medications (Daily)

Medication Name	Dosage	Route (Oral/Topical/Inhaled)	Time(s) to Administer	Start Date	End Date

As-Needed Medications (Emergency)

For emergency epinephrine, rescue inhalers, etc.

Medication Name	Dosage	Route	Circumstances for Use	Prescribing Physician	Physician Phone

Parent/Guardian Signature

Date

Prescribing Physician Name

Physician Phone

Form 7.Photo/Media Release

Select one option below.

I GRANT permission

for my child's photo/image to be used for:

Classroom displays
Center newsletters
Center social media accounts
Center website
Promotional materials

I DO NOT GRANT permission

for any photo/image use beyond internal classroom purposes.

Parent/Guardian Signature

Date

Form 8.Tuition Agreement

Schedule of Care

Days of Week

Mon / Tue / Wed / Thu / Fri

Drop-off Time

Pickup Time

Fees & Rates

Tuition Rate

$ _______ per week / month

Registration Fee (non-refundable)

$ _______

Annual Supply Fee (if applicable)

$ _______

Payment Due Date

Day of week / month

Accepted Payment Methods

Late & Penalty Fees

Late Payment Fee

$ _______ per day after grace period

Returned Payment Fee

$ _______

Late Pickup Fee

$ _______ per minute after ___:___ PM

Withdrawal Policy

Written Notice Required

_______ weeks

Tuition Due Through Notice Period

Yes / No

Subsidy & Tax Information

Accepted Subsidy Programs

State program names

Tax ID / EIN for Dependent Care FSA Claims

Parent/Guardian Signature

Date

Center Director Signature

Date

Form 9.Handbook Acknowledgment & Consent

"I, [parent name], have received and read the [Center Name] Family Handbook. I understand and agree to abide by all policies and procedures outlined therein. I understand that the handbook may be updated periodically and that I will be notified of any significant changes."

Additional Consents

I consent to emergency medical treatment if I cannot be reached.
I consent to application of sunscreen/insect repellent.
I consent to my child participating in water play activities.
I consent to walking field trips within [distance] of the center.

Parent/Guardian Signature

Date

Child's Name

Sources: Based on enrollment form requirements from TX HHS, CA CDSS LIC 311A, FL DCF, WA DCYF, ME DHHS, Brightwheel enrollment forms research, and common state licensing standards. Requirements vary by state - verify with your licensing agency. Last updated March 2026.

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