Child’s Preadmission Record (continued) page two of two form not valid without first page – – Church Affiliation Father Mother How did you find out about our center? (Referred by) Describe any special or instructions below: Person(s) the child may be released to: Name Relationship to Child Address Telephone Number I understand that the Department of Human Resources does not inspect activities away from the child care facility (home or center). The licensee of the childcare facility assumes full responsibility for such activities. ___________________________/_______________ Signature of parent/guardian Date I give my child permission to participate in: (Circle yes or no and sign each line) Signature of parent/guardian Date Activities away from the facility: yes no Signature of parent/guardian Date Transportation provided by the facility: yes no Signature of parent/guardian Date Swimming/wading activities provided by the yes no facility: Form not valid without signature of child’s parent/guardian in each space indicated above. This section to be completed by the facility’s staff. Child’s first day of attendance: _______________ Child’s withdrawal date: _______________ Additional information may be attached.
Child’s Preadmission Record (continued) – page two of two – form not valid without first page Church Affiliation Father Mother How did you find out about our center? (Referred by) Describe any special or instructions below: Person(s) the child may be released to: Name Relationship to Child Address Telephone Number I understand that the Department of Human Resources does not inspect activities away from the child care facility (home or center). The licensee of the childcare facility assumes full responsibility for such activities. ___________________________/_______________ Signature of parent/guardian Date I give my child permission to participate in: (Circle yes or no and sign each line) Activities away from the facility: yes no Signature of parent/guardian Date Transportation provided by the facility: yes no Signature of parent/guardian Date Swimming/wading activities provided by the facility: yes no Signature of parent/guardian Date Form not valid without signature of child’s parent/guardian in each space indicated above. This section to be completed by the facility’s staff. Child’s first day of attendance: _______________ Child’s withdrawal date: _______________ Additional information may be attached.
jca_early_learning_center_registration_forms-2.docx