Child Registration Form - The Children's Nest Preschool and Daycare

The Children’s Nest Preschool and Daycare
1155 Draper Road SW, Blacksburg, VA 24060
Child Registration Form
Child’s Name ___________________________ Nickname_____________ Sex ____ Birthdate ___________
Address _______________________________________________________ Home Phone _________________
Parents/Guardians:
Father’s Name __________________________________________________ Cell Phone _________________
Place of Employment _____________________________________________ Work Phone ________________
Home Address and Phone (if different from child) ____________________________________________________
Mother’s Name __________________________________________________ Cell Phone _________________
Place of Employment _____________________________________________ Work Phone ________________
Home Address and Phone (if different from child) ____________________________________________________
Person(s) or Agency having legal custody of child ___________________________________________________
Home Address ___________________________________________ Home Phone ______________________
Business Address _________________________________________ Business Phone ____________________
Emergency Information for Child:
Name of Child’s Physician __________________________________________ Phone ____________________
Allergies or intolerance to food medication, etc. ______________________________________________________
Please list any other medical issues (including, but not limited to, any developmental delays, chronic conditions, and
any other physical, emotional or cognitive issues) ____________________________________________________
Local Emergency Contacts (if parents/guardians cannot be reached)
Name Address Phone Relationship to Child
1. _________________________________________________________________________________________
2. _________________________________________________________________________________________
Person(s) authorized to pick up child ______________________________________________________________
Person(s) NOT authorized to visit or pick up child ____________________________________________________
If child attends this center and another school:
Name of School ___________________________________ Phone ______________________ Grade _____
Parent Agreements (please initial)
1. I, the parent/guardian, authorize The Children’s Nest Preschool and Daycare to take my child on field trips
when feasible. Permission slips will be distributed for parent/guardian to sign before all field trips. _____
2. The Children’s Nest Preschool and Daycare agrees to notify the parent/guardian when the child becomes ill
and the parent/guardian agrees to pick the child up as soon as possible thereafter. ______
3. I, the parent/guardian, authorize The Children’s Nest Preschool and Daycare to obtain immediate medical
care if an emergency occurs and I cannot be reached. ______
4. I, the parent/guardians, authorize The Children’s Nest to take photographs of my child during daily activities
and to post the pictures in the classroom. ______
5. I, the parent/guardian, authorize The Children’s Nest and/or their website developer to take pictures of my
child during daily activities and post them on The Children’s Nest Website. No names will be used. ______
Signature: ___________________________________________ Date _______________________________
Date Admitted ________________________________________ Date Withdrawn ______________________
Administrator/Director Signature __________________________ Date _______________________________
Please fill out this form, sign it, scan it, and email the file to [email protected]ChildrensNest.com or mail it via postal mail or bring it to the office.
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