Child Enrollment Application

Kidz at Hart Quality Child Care

Child and household information

1

Child’s full name

Birth date

Requested start date

Gender Female Male

Primary household phone

Primary parent or guardian email

Home address

Child resides with

Number of people in household

Parental status

Other status

Custody restrictions or court orders

Custody document, when applicable

Parents and guardians

Mother

Name

Address, if different from child

Phone

Date of birth

Driver’s license number

Employer or school

Work or school phone

Employer or school address

Father

Name

Address, if different from child

Phone

Date of birth

Driver’s license number

Employer or school

Work or school phone

Employer or school address

Legal guardian other than mother or father

Name

Address, if different from child

Phone

Date of birth

Driver’s license number

Employer or school

Work or school phone

Employer or school address

Kidz at Hart Quality Child Care

Emergency contacts and authorized pickup

2

Child’s name

Date of birth

Emergency contacts not listed as parents or guardians

Name	Relationship	Physical address	Telephone number	May pick up?

People specifically allowed to pick up

Name	Relationship	Physical address	Telephone number

People not allowed to pick up

Name

Relationship to child

Name

Relationship to child

Other restrictions on child pickup

The uploaded West Virginia form states that biological or custodial parents must be given access to their children unless there is a court order preventing contact.

Kidz at Hart Quality Child Care

Requested days and hours of care

3

Child’s name

Requested start date

Staff is scheduled according to the requested hours, so complete the expected arrival and departure times as accurately as possible.

Day	Care needed?	Arrival time	Departure time	Notes
Monday
Tuesday
Wednesday
Thursday
Friday

Additional schedule, transportation, school, or bus information

Child’s school

School phone

School address

Bus number

Kidz at Hart Quality Child Care

Medical, insurance, and special-needs information

4

Child’s name

Date of birth

Does the child have a diagnosed medical condition? Yes No

If yes, explain

Does the child have a current IEP? Yes No

IEP copy, if applicable

Regular medications, including dosage or instructions

Allergies, illnesses, special needs, and other concerns

Other information

Insurance company

Policy number

Child’s doctor

Doctor’s phone

Doctor’s address

Child’s dentist

Dentist phone

Dentist address

Preferred hospital or clinic for emergency care

Required or supporting records

Current physical is attached Current shot or immunization record is attached Health insurance card is attached

Physical record

Shot or immunization record

Insurance card

Kidz at Hart Quality Child Care

Permissions, releases, and parent rights

5

Child’s name

Date of birth

Emergency medical treatment and transportation release

I authorize the center or any of its employees to call a physician to secure necessary medical care in the event of an emergency. I authorize the center to act in my behalf to protect my child when I cannot be reached or when delayed. I also give my consent to have my child transported by ambulance or authorized vehicle to a medical facility. I understand that the center will make every possible effort to contact me and/or emergency contacts on file.

I acknowledge and authorize this emergency medical release.

Parent rights acknowledgement

The center prohibits corporal punishment on its premises.
As a parent, you have access to the center while your child is in attendance.
You have read and understand and have a right to a copy of the center’s policies on behavior management and child abuse and neglect.
All information is considered confidential and will not be released without written approval.
You have the right to report complaints related to child-care licensing requirements.

I acknowledge the parent rights listed above.

Permission choices

Permission	Allow	Do not allow	Parent initials
Have sunscreen applied for outdoor play
Be observed for educational purposes
Be assessed for developmental screenings
Be photographed and videoed for classroom activities and displays
Have the child’s photo used on Kidz at Hart private social media pages, including Facebook and/or DOJO

Security camera acknowledgement

The uploaded photograph permission page states that security cameras with video and audio are always running and that this is required to attend daycare.

I acknowledge the center’s security camera statement.

General authorizations and emergency release signature

Sign to confirm the emergency medical release, parent-rights acknowledgement, and the permission choices above.

Sign above this line

Printed name of parent or guardian

Date signed

Signature not captured.

Classroom photograph, video, and security-camera signature

Sign to confirm the classroom photograph/video selection and acknowledgement of the center’s security cameras.

Sign above this line

Printed name of parent or guardian

Date signed

Signature not captured.

Private social-media permission signature

Sign to confirm the permission choice for the child’s photograph on private Facebook and/or DOJO pages.

Sign above this line

Printed name of parent or guardian

Date signed

Signature not captured.

Permission to receive medical care

I, , give my permission for to consent for to receive emergency medical, dental, or surgical treatment if I cannot be reached.

Restrictions on medical treatment

Permission to transport

I do not give the child-care provider permission to transport my child for non-emergency reasons. I give the child-care provider permission to transport my child for non-emergency reasons, such as school or school activities, shopping, field trips, or similar activities. In the event of an emergency, I prefer that the child-care provider call an ambulance to transport my child. In the event of an emergency, I give permission for the child-care provider to transport my child.

Restrictions on transportation

Medical-care and transportation consent signature

Sign to confirm the medical-treatment and transportation selections and restrictions in this section.

Sign above this line

Printed name of parent or guardian

Date signed

Signature not captured.

Kidz at Hart Quality Child Care

Certification and signatures

6

Child’s name

Date of birth

Parent or guardian certification

To the best of my ability and knowledge, the information on this form is correct. If anything changes, such as address, phone number, employment, or number of persons in the home, I will notify the center.

I certify that the information in this application is correct.

Enrollment information certification signature

Sign to certify that the child and household information in this application is complete and correct.

Sign above this line

Printed name of parent or guardian

Date signed

Signature not captured.

Enrollment date

Discharge date

Application checklist

Enrollment application completed Current physical included Immunization or shot record included Insurance card included Custody documents included, when applicable IEP included, when applicable Free and reduced price school meals application reviewed

Submitting online also sets up your parent portal login with the email address above. Use it to follow this application, message the office, and manage your family's records once enrolled.

Choose a password At least 8 characters. Skip this only if you already have a parent account.

Confirm password

Child enrollment application

Child and household information

Parents and guardians

Emergency contacts and authorized pickup

Emergency contacts not listed as parents or guardians

People specifically allowed to pick up

People not allowed to pick up

Requested days and hours of care

Medical, insurance, and special-needs information

Required or supporting records

Permissions, releases, and parent rights

Emergency medical treatment and transportation release

Parent rights acknowledgement

Permission choices

Security camera acknowledgement

General authorizations and emergency release signature

Classroom photograph, video, and security-camera signature

Private social-media permission signature

Permission to receive medical care

Permission to transport

Medical-care and transportation consent signature

Certification and signatures

Parent or guardian certification

Enrollment information certification signature

Application checklist

Create your parent account