Child Registration Form

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IMPORTANT

We are happy to help you! If any part of this registration confuses you or is otherwise difficult, please reach out to us by calling (804) 318-1727 or texting (804) 496-9068 or email us at masseychildcare1@gmail.com.

All information must be consistent with government documents. For example, parent names must match the birth certificate. If one or more birth parents do not have custody, you will indicate this in the field "PERSON(S) OR AGENCY HAVING LEGAL CUSTODY OF CHILD". However, we must have documentation of any protective order against a birth parent and custody arrangements that do not give custody to a birth parent.

We also require two emergency contacts that are not the legal guardians. Legal guardians are already the first to be contacted in an emergency. Emergency contacts are contacted if and only if we cannot reach the legal guardians.

Indicate "N/A" if a field is not applicable.

The information in this form is required by Child Day Center Standards 8VAC20-780-60.

Child Information

First Name

Last Name

Nickname

Date of Birth

Sex

Address

Street Address

City

State

ZIP Code

Home Phone

Chronic Physical Problems/Pertinent Developmental Information/Special Accommodations Needed

Previous Child Day Care Programs and Schools Attended

If Child Attends this Center and Another School/Program, Give Name of School/Program

Grade/Class Level

Parent(s)/Guardian(s)

Birth Parent as established in government documents

Parent 1 Name (First and Last)

Place Employed (Parent 1)

Work Phone (1)

Home Address (1)

Same as Child's?

Street Address

City

State

ZIP Code

Home Phone (1)

Birth Parent as established in government documents (Enter "none" if there is no second birth parent, living or deceased, on government documents and enter "none" on the address and phone number if the birth parent does not have an address or phone number)

Parent 2 Name (First and Last)

Place Employed (Parent 2)

Work Phone (2)

Home Address (2)

Same as Child's?

Street Address

City

State

ZIP Code

Home Phone (2)

Person(s) or Agency Having Legal Custody of Child

Home Address of Above

Same as Child's?

Street Address

City

State

ZIP Code

Home Phone

Work Address of Above

Street Address

City

State

ZIP Code

Work Phone

Emergency Information

Allergies or Intolerance to Food, Medication, etc., and Action to Take in an Emergency

Does child have either an intolerance or an allergy?Allergy (Diagnosed by Doctor)IntoleranceNo known allergy or intolerance

Full Response:

Child's Physician

Physician's Office Address

Street Address

City

State

ZIP Code

Physician's Phone

DO NOT ENTER PARENTS' NAMES. People to Contact If Parent/Guardian Cannot Be Reached

First Emergency Contact

Address of 1st Emergency Contact

Street Address

City

State

ZIP Code

Phone (1st)

Second Emergency Contact

Address of 2nd Emergency Contact

Street Address

City

State

ZIP Code

Phone (2nd)

Person(s) Authorized to Pick Up Child (first and last name as it appears on their ID)

Person(s) NOT Authorized to Pick Up Child *

Appropriate paperwork, such as custody papers, shall be attached if a parent is not allowed to pick up the child.
NOTE: Section 22.1-4.3 of the Code of Virginia states that unless a court order has been issued to the contrary, the noncustodial parent of a student enrolled in a public school or day care center (i) shall not be denied the opportunity to participate in any of the student's school or day care activities in which such participation is supported or encouraged by the policies of the school or day care center solely on the basis of such noncustodial status and (ii) shall be included, upon the request of such noncustodial parent, as an emergency contact for the student's school or day care activities.

Agreements

The child day center agrees to notify the parent(s)/guardian(s) whenever the child becomes ill and the parent(s)/guardian(s) will arrange to have the child picked up as soon as possible if so requested by the center.
The parent(s)/guardian(s) authorize the child day center to obtain emergency medical care if any emergency occurs when the parent(s)/guardian(s) cannot be located immediately. **
The parent(s)/guardians agree to inform the center within 24 hours or the next business day after his child or any member of the immediate household has developed a reportable communicable disease, as defined by the State Board of Health, except for life threatening diseases which must be reported immediately.

Signatures

Parent(s) or Guardians(s) Signature

Signature not recorded until you click "Save Signature"

Name (Print)

Date of Signature

** If there is an objection to seeking emergency medical care, a statement should be obtained from the parent(s) or guardian(s) that states the objection and the reason for the objection.