Creative Years Registration Form

Please note that the completion of this form DOES NOT guarantee a spot for your child(ren).
You will be contacted directly when we have an opening in any of the age appropriate programs.

 

Requested Date of Enrollment:                                                      Facility License Number: 1056

Child Information

1^st Child First Name: M.I. Last Name:

Child’s Address:

Gender: [] Male [] Female  Date of Birth:

List any existing medical conditions, medication and/or special attention your child may require?

Allergies:

Pediatrician’s Name:     Phone:

Address:

 

2^nd Child First Name: M.I. Last Name:

Child’s Address:

Gender: [] Male [] Female  Date of Birth:

List any existing medical conditions, medication and/or special attention your child may require?

Allergies:

Pediatrician’s Name: Phone:

Address:

 

3^rd Child First Name: M.I. Last Name:

Child’s Address:

Gender: [] Male [] Female  Date of Birth:

List any existing medical conditions, medication and/or special attention your child may require?

Allergies:

Pediatrician’s Name:     Phone:

Address:

 

Parent/Guardian Information

Parent 1/Guardian  First Name: M.I. Last Name:

Address:

Occupation: Home Phone:

Employed By: Office Phone:

Work Address: Work Hours: Cell Phone:

[] Custodial Parent (If married, mark both parents)

Email:

Parent 2/Guardian  First Name: M.I. Last Name:

Address:

Occupation: Home Phone:

Employed By: Office Phone:

Work Address: Work Hours: Cell Phone:

[] Custodial Parent (If married, mark both parents)

Email:

 

Emergency Contacts & Authorized Pickup Persons:

1^st Contact/Pick Up Name: Phone:

Relationship to the Child:

2^nd Contact/Pick Up Name: Phone:

Relationship to the Child:

3^rd Contact/Pick Up Name: Phone:

Relationship to the Child:

4^th Contact/Pick Up Name: Phone:

Relationship to the Child:

 

Signature:

Parent or Guardian Signature:
(Typing your name will be taken as your electronic signature)

Date:

Note to Parents

NOTE TO PARENT/S or GUARDIAN/S: 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 for parents to review upon request. Statements of findings and corrective action plans are also available on-line at http://childcaresearch.dhhs.nh.gov or by calling the unit at 1-800-852- 3345, extension 4624
or 603-271-4624.

During licensing, monitoring, and complaint investigation visits to licensed programs the department shall speak with children regarding the care they receive at the program, if in the judgment of the licensing coordinator the children's response would be valuable in determining compliance with licensing rules. Licensing staff are experienced in working with children and trained to interview in a manner that is respectful and non-leading. However, if you do not want your child interviewed, or if you wish to be informed prior to your child being interviewed you must give the family child care provider, center director, site director or designee, and update annually, a signed dated statement indicating your preference.

For more information about Child Care Licensing please visit our website at: www.dhhs.state.nh.us/DHHS/BCCL/default.htm

Photography Policy

Throughout the school year we do take photos of the children for various projects or classroom decoration. These photos are not shared with the public and are used strictly for educational purposes. Please sign below to provide your consent to having your child's picture taken by school personnel.

Signature:

Parent or Guardian Signature:
(Typing your name will be taken as your electronic signature)

Date:

 

Emergency Medical Treatment Authorization

I hereby give permission for the staff of Creative Years to provide simple first aid treatment to my child, when necessary, and 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 emergency 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 a child care program personnel as soon as possible regarding any emergency involving my child.

Signature:

Parent or Guardian Signature:
(Typing your name will be taken as your electronic signature)

Date:

 

Annual Update:

Parent/Guardian must review this information annually, make necessary changes and initial and date below to verify that the information is current.

Date of Review:

Parent/Guardian Initials:

Date of Review:

Parent/Guardian Initials:

Date of Review:

Parent/Guardian Initials:

Date of Review:

Parent/Guardian Initials: