MILESTONES CHILD CARE REGISTRATION FORM

Child’s name: Nickname: Birth date:

Child’s parent/guardian name: Home phone #: Cell phone #: Alternative #:

Home Address:

Address where you can be reached when child is in care:

Child’s parent/guardian name: Home phone #: Cell phone #: Alternative #:

Home Address:

Address where you can be reached when child is in care:

Other than you who has permission to pick up your child?

Name Address Telephone number
Name: Home:
Relationship: Cell:
Alternative:
In case of an emergency, I give permission for any of the following individuals to be
contacted and my child may be released to any of them.

Parent/guardian signature: ____________________________

Name Address Telephone number

Name: Home:
Relationship: Cell:
Alternative:
Name: Home:
Relationship: Cell:
Alternative:
Who does not have permission to pick your child? If applicable (a copy of supporting court
document must be on file)
Name: Reason:

Child Health Information

Child’s Pediatrician: Contact number:
Landline:
Cell:
Address:

Special health problem? Yes or No? If Yes, Allergies, including drug reactions
specify. Yes or No? If Yes, specify

Consent to medical care and treatment of minor children

I give permission that my child ________________________________, may be given
first aid/emergency treatment by a child care provider/qualified staff at Milestones.

Parent/guardian signature: Date: Parent/guardian signature: Date:

When I cannot be contacted, I authorize and consent to medical/hospital care/treatment

to be performed by a licensed physician/health care provider, hospital or aid car assistant
when deemed necessary or advisable by a physician to safeguard my child’s health.
I also give my permission for my child to be transported by ambulance or aid car to a
hospital for treatment.

Parent/guardian signature: Date: Parent/guardian signature: Date:

Note: Please provide the following when submitting this form

 4 passport sized pictures of your child.
 Allergy list (in case of children who have allergies)
 Vaccination card
 2 passport sized pictures of both parents/guardian
 Copy of your NIC or Passport