Child Care Registration Form
To the Parent or Guardian: This form must be completed for each of your children who will be enrolled in the program, and must be updated whenever information changes.
Date of Child's Enrollment
Child's Name
Child's Date of Birth
Street Address
Apartment (optional)
City
State
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Washington DC Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip
Phone Number
Identifying Information of Parent/s or Guardian/s Legally Responsible for Child
Parent / Guardian #1 -
Name
Street Address
Apartment (optional)
City
State
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Washington DC Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip
Home Phone Number
Parent / Guardian #2 -
Name
Street Address
Apartment (optional)
City
State
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Washington DC Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip
Home Phone Number
Please Indicate Where Parent/Guardian Above Can be Reached While Child is in Care. Include Name, Address and Phone Number of Business if Applicable.
Parent / Guardian #1
Business Name
Street Address
Apartment / Suite / Other (optional)
City
State
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Washington DC Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip
Phone Number
Hours
Email
Parent / Guardian #2
Business Name
Street Address
Apartment / Suite / Other (optional)
City
State
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Washington DC Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip
Phone Number
Hours
Email
Special Instructions for Reaching Parent/Guardian
Emergency Contact(s)
You (parent/guardian) are required to list at least 1 person with whom you would feel comfortable leaving your child, and who could assume responsibility for your child if you could not be reached immediately in an emergency, or if for some reason you could not pick up your child and were unable to communicate with the program. Examples: if your child were sick and you were not accessible, or if you experienced sudden illness between work and picking up your child.
Emergency Contact #1
Name
Relationship
Street Address
Apartment (optional)
City
State
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Washington DC Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip
Phone Number
Emergency Contact #2
Name
Relationship
Street Address
Apartment (optional)
City
State
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Washington DC Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip
Phone Number
Non-Emergency Alternate Pick-Up Contact(s)
I, , authorize the following individuals(s) to pick up my child from the program on a non-emergency basis.
Alternate Contact #1
Name
Relationship
Street Address
Apartment (optional)
City
State
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Washington DC Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip
Phone Number
Alternate Contact #2
Name
Relationship
Street Address
Apartment (optional)
City
State
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Washington DC Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip
Phone Number
Licensing Staff & Medical Information
The licensing authority for this program is the bureau of licensing and certification, child care licensing unit. Child care programs are required to post a copy of the statement of findings and corrective action plan for the most recent visit in a location which is accessible to parents, and must maintain copies of the statement of findings and corrective action plan for the preceding visit and make them available to parents to review upon request. Statements of findings and corrective action plans are also available online at https://nhlicenses.nh.gov/verification/Search.aspx?facility=’Y or by calling 603-271-9025 or 1-800-852-3345, extension 9025 .
During visits to programs licensing staff speak with children regarding the care they receive at the program if in the judgment of the licensing staff the children’s response would be valuable in determining compliance with licensing rules. Licensing staff are experienced in working with children and trained to speak with children in a manner that is respectful and non-leading. Children will remain with their class or group during these conversations with licensing staff, and at no time will a child be forced to speak with a licensing coordinator.
Licensing Staff Permission
If licensing staff believes your child may have specific information regarding an alleged event at the child care program, and determines that it is best to interview your child separately and not with their class or group, please indicate your preference among the following options:I give permission for child care licensing staff to interview my child at the child care program separate from their class or group I wish to be notified prior to child care licensing staff interviewing my child at the child care program separate from their class or group I do not give permission for child care licensing staff to interview my child at the child care program separate from their class or group For more information about Child Care Licensing please visit: https://www.dhhs.nh.gov/oos/cclu/index.htm
Any chronic conditions, allergies, or medications that could be important in case of sudden illness or injury
Child's Usual Physician
Physician's Phone Number
Physician's Address
Emergency Medical Treatment Authorization
I hereby give permission for the staff of "Dynamic Foundations" for Families to provide simple first aid treatment to my child, when necessary. In the event of a more serious illness or injury, I give permission for my child to be transported to a hospital or other emergency medical facility to receive medical treatment. I also authorize ambulance/rescue squad attendants to administer such treatment as is medically necessary, and I authorize licensed health practitioners working in the hospital or emergency medical facility to examine and provide emergency medical treatment to my child if warranted. I understand that I will be contacted by child care program personnel as soon as possible regarding any emergency involving my child.