Student Registration Form

  • Student Information

  • Date Format: MM slash DD slash YYYY
  • Parent/Guardian Information

  • Emergency Info

  • Please list 2 LOCAL emergency contacts that are NOT the parents or guardians of the child.
  • Please list 2 LOCAL emergency contacts that are NOT the parents or guardians of the child.
  • Agreements

    1. 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.
    2. The parent(s)/guardian(s) authorize the child day center to obtain immediate medical care if any emergency occurs when the parent(s)/guardian(s) cannot be located immediately. **
    3. 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.

    * 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 must be included, upon the request of such noncustodial parent, as an emergency contact for events occurring during school or day care activities. 032-05-252/11 (06/05)

  • Date Format: MM slash DD slash YYYY