Massey Childcare

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 or Class Level

Parent(s)/Guardian(s)

Parent 1 Name (First and Last)

Place Employed (Parent 1)

Work Phone (1)

Home Address (1)

Street Address

City

State

ZIP Code

Home Phone (1)

Parent 2 Name (First and Last)

Place Employed (Parent 2)

Work Phone (2)

Home Address (2)

Street Address

City

State

ZIP Code

Home Phone (2)

Emergency Information

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

Child's Physician

Physician's Office Address

Street Address

City

State

ZIP Code

Physician's Phone

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

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

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.