Child Enrollment Form — page 2

Wylari

Emergency Contacts (other than parents)

Contact 1 — name

Relationship

Phone

Contact 2 — name

Relationship

Phone

Authorized for Pick-Up

Only the people listed below (and the parents/guardians above) may pick this child up. Photo ID will be checked.

Name

Relationship

Phone

Name

Relationship

Phone

Name

Relationship

Phone

Health & Medical

Child's physician

Physician phone

Insurance provider

Allergies (food, medication, environmental) — describe reactions

Dietary restrictions or feeding notes

Current medications and instructions

Medical conditions, special needs, or anything else we should know

Please attach a current immunization record if required in your state.

Permissions

I authorize emergency medical treatment for my child if a parent cannot be reached immediately.

My child may appear in photos used inside the program (daily updates to enrolled families).

Provider may apply sunscreen, diaper cream, and insect repellent supplied or approved by me.

My child may take part in neighborhood walks and outdoor play.

Signatures

Parent / guardian signature

Date

Provider signature

Date

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