Pasadena Childcare Registration Form

Childcare Registration Form
Child's Information
Student First Name
Student Middle Name
Please enter the student’s middle name. If there is no middle name, write ‘N/A’.
Student Last Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex/Gender
Ethnicity
Race
Home Street Address
City
State
Zip Code

Parent/Guardian Information
Parent 1 Full Name
Parent 1 Relationship to Child
Parent 1 Email
example@example.com
Parent 1 Cell Phone
Format: (000) 000-0000.
Parent 1 Home Street Address
Parent 1 City
Parent 1 State
Parent 1 Zip Code
Parent 1 Employer
Parent 1 Occupation
Parent 1 - Is this parent an emergency contact?
Parent 1 - Authorized to pick up?
Parent 1 State that issued ID
Parent 1 ID Number
If not applicable, type in “000-000-0000"

Parent/Guardian 2
Parent 2 Full Name
Parent 2 Relationship to Child
Parent 2 Email
example@example.com
Parent 2 Cell Phone
Format: (000) 000-0000.
Parent 2 Home Street Address
Parent 2 City
Parent 2 State
Parent 2 Zip Code
Parent 2 Employer
Parent 2 Occupation
Parent 2 - Is this parent an emergency contact?
Parent 2 - Authorized to pick up?
Parent 2 State that issued ID
Parent 2 ID Number
If not applicable, type in “000-000-0000"

Emergency Contact Person 1

Must be different from the parents
Emergency Contact 1 Full Name
Emergency contacts MUST be different than the parents
Emergency Contact 1 Relationship to Child
Emergency Contact 1 Email
example@example.com
Emergency Contact 1 Cell Phone
Format: (000) 000-0000.
Emergency Contact 1 Home Address
Emergency Contact 1 City
Emergency Contact 1 Zip Code
Emergency Contact 1 State that issued ID
Emergency Contact 1 ID Number
If not applicable, type in “000-000-0000"
Emergency Contact 1 Authorized to pick up?
Emergency Contact Person 2
Emergency Contact 2 Full Name
Emergency contacts MUST be different than the parents
Emergency Contact 2 Relationship to Child
Emergency Contact 2 Email
example@example.com
Emergency Contact 2 Cell Phone
Format: (000) 000-0000.
Emergency Contact 2 Home Address
Emergency Contact 2 City
Emergency Contact 2 Zip
Emergency Contact 2 State that issued ID
Emergency Contact 2 ID Number
If not applicable, type in “000-000-0000"
Emergency Contact 2 Authorized to pick up?

Acknowledgement
I acknowledge that I have access to the childcare center family handbook and will abide by all policies,procedures, and guidelines as provided:
My signature below acknowledges my understanding and agreement to each of the above consents.
Parent Signature
Signature Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent Name

Does your child currently have any limitatios to physical activity?
If yes please explain
Does your child require any special equipment for daily activities?
If yes please explain the equipment needed
Allergies and Medication
Does your child require medication every day or as needed? If “Yes”, doctor documentation will be required.
If yes please list the name of the medicine dosage how many times per day and time taken prescribing physician
Does your child have any known allergies? If “Yes”, doctor documentation will be required.
If yes, please explain and list any prescribed medications

Does your child have diagnosed food allergies? (If Yes, documentation will be required.)
If yes please describe the food restrictions
Does your child have food preferences that are not due to allergies? (e.g., for religious, cultural, or personal reasons)
If yes please describe them
My child attends the following school
School Phone Number
If not applicable, type in “000-000-0000"Format: (000) 000-0000.
Child's required immunizations, vision and hearing screening, and TB screening are current and onfile at their school:
Schedule of care
I will be needing the following schedule of care:

Medication Administration
1. All medications will be kept in a locked medicine box, this is for your child’s safety as well as the safety of other children. Medicine is not allowed to stay in the children’s bags or cubbies ever:
In the event I cannot be reached to make arrangements for emergency medical care, I authorize the person in charge to take my child to
Name of Physician
If your child does not have a primary physician, please provide the name of the closest physician or medical clinic to you.
Physician Address
Physician Phone Number
If not applicable, type in “000-000-0000"Format: (000) 000-0000.
Name of Emergency Care Facility
Care Facility Address
Care Facility Phone Number
If not applicable, type in “000-000-0000"Format: (000) 000-0000.
Toilet Training
1. I understand that it is not the responsibility of teachers to change diapers. This task falls solely on the parents. In the event that a diaper change is required, the parent will be contacted to address the situation.:
All About Me
Child Lives with:
Primary Language spoken at home
Other languages spoken at home

Are there other siblings/family members in the home?
If yes, please name names and ages
Do you have backup care arrangements in place in case of illness or center closure?
Are there any other comments or information you would like the center to know?
Specific Concerns
Parent Signature

Operational Discipline and Guidance Policy
Discipline must be:

1) individualized and consistent for each child;

2) appropriate to the child’s level of understanding; and

3) directed toward teaching the child acceptable behavior and self-control.

A caregiver may only use positive methods of discipline and guidance that encourage self-esteem, self-control and self-direction,which include at least the following:

1) using praise and encouragement of good behavior instead of focusing only upon unacceptable behavior;

2) reminding a child of behavior expectations daily by using clear, positive statements;

3) redirecting behavior using positive statements; and

4) using brief supervised separation or time out from the group, when appropriate for the child’s age and development, which is limited to no more than one minute per year of the child’s age.

There must be no harsh, cruel, or unusual treatment of any child. The following types of discipline and guidance are prohibited:

1) corporal punishment or threats of corporal punishment;

2) punishment associated with food, naps or toilet training;

3) grabbing or pulling a child;

4) putting anything in or on a child’s mouth;

5) humiliating, ridiculing, rejecting or yelling at a child;

6) subjecting a child to harsh, abusive or profane language;

7) placing a child in a locked or dark room, bathroom or closet;

8) placing a child in a restrictive device for time out;

9) withholding active play or keeping a child inside as a consequence for behavior, unless the child is exhibiting behavior during active play that requires a brief supervised separation or time out that is consistent with 746.2803(4)(D); and

10) requiring a child to remain silent or inactive for inappropriately long periods of time for the child’s age.
This policy is effective on the following date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signed by
Type a question
Should be Empty:

Childcare Registration Form

Child's Information

Parent/Guardian Information

Parent/Guardian 2

Family Status

Emergency Contact Person 1

Emergency Contact Person 2

Consents and Agreements

Medical Information

Medical Consents and Agreements

All About Me

Operational Discipline and Guidance Policy