Enroll A New Child - Kessel Kids Child Care & Learning Center

Child's Information

Child's Name

(First, Middle, Last)

Preferred Name

Date of Birth

MM/DD/YYYY

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Ethnicity

H = Hispanic or Latino
N = Non Hispanic or Latino

Race (Select one or more)

This information is requested by the Federal Government in order to monitor compliance with Civil Rights law. You are not required to furnish this information, but are encouraged to do so. The law requires that organizations may not discriminate on the basis of this information nor whether you choose to furnish it.

Child at a Glance

Approximate schedule at center

Primary language

Likes

Dislikes

Medical and Dental Information

(A healthcare and dental provider is required)

Child's Primary Provider

Phone

Hospital of Choice

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Health Insurance

Child has health insurance
Child does not have health insurance

Insurance Provider

Policy Number

Dentist of Choice

Phone

Dental Facility

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Dental Insurance

Child has dental insurance
Child does not have dental insurance

Dental Provider

Allergies, existing medical conditions, medications, special needs or instructions

Parent / Guardian Info (1)

Name

Relationship to Child

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Home Phone

Mobile Phone

Preferred Email

Place of Work

Work Phone

Work Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Parent / Guardian Info (2)

Name

Relationship to Child

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Home Phone

Mobile Phone

Preferred Email

Place of Work

Work Phone

Work Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Secondary Emergency Contacts

(secondary contacts will be used when the parents cannot be reached)

Name

Contact Number

Allowed for pickup

Allowed to pick up child/children from facility

Relationship to Child

Place of Employment

Name

Contact Number

Allowed for pickup (copy)

Allowed to pick up child/children from facility

Relationship to Child

Place of Employment

Name

Contact Number

Allowed for pickup (copy) (copy)

Allowed to pick up child/children from facility

Relationship to Child

Place of Employment

Additional Pickups not considered emergency contacts

Name

Contact Number

Relationship to Child

Place of Employment

Name

Contact Number

Relationship to Child

Place of Employment

Name

Contact Number

Relationship to Child

Place of Employment

Name

Contact Number

Relationship to Child

Place of Employment

***Please note anyone that is UNABLE to pick up the child or children in care. A copy of the court order is required if a parent is listed.

Consent and Releases

(Individual permission slips will be issued for special events outside of the center)

Public Transit Consent

Consent is given for my child to utilize public transit when age-appropriate

School District Transport Consent

Consent is given for my child to utilize Howard Winneshiek School District’s transportation services when age-appropriate

Photo Release *

My child may be photographed while in child care. Photos may be used in newspapers or other media for the purpose of publicity or shared with other families whose children attend the child care program.
Decline Photo Release

Walking/Stroller Rides Consent

Consent is given for walking/stroller rides within school district property

Playground Consent

Consent is given to utilize Howard Winneshiek School Districts elementary school playground when age-appropriate

Signature

I have received and read the Parent Handbook.

Date