C.A.S.T.L.E. Child Care Enrollment Form

C.A.S.T.L.E. Child Care Enrollment Form

Child’s Last Name______First______

Grade_____ Choose one: Park Side ____ Brook Haven ____ Other______

Child’s Birth Date______Age______M ( ) F ( )

Parent/Guardian’s Name(s):______

Child’s Address: ______City: ______Zip:______

Other Address :______City:______Zip:______

Mother Home Phone:______Father Home Phone:______

E-Mail Address(es):______

Person Responsible for Paying Tuition: ______

Child lives with: ______

***Call this number first in case of emergency!______***

Mother/Guardian Name: ______

Mother/Guardian Employer’s name and address ______

SS# ______Driver’s License ______State: ______

Business phone:______ext.____Pager #______Cell______

Father/Guardian Name: ______

Father/Guardian Employer’s name and address______

SS#: ______Driver’s License______State:______

Business phone:______ext.____Pager #______Cell______

My child has permission to participate in walking field trips while enrolled in CASTLE. Yes______No______Please initial _____

Siblings attending CASTLE? ___ Name______Grade_____

Yes, I have received and read my handbook and understand I am responsible for the information contained therein. I realize I must sign my child in (if participating in the AM program) and out each day. We close at 6:00 PM. Late parents will be charged $1.00/minute; 3 late pickups may equal expulsion from the program. CASTLE has specific behavior guidelines that must be met for the success and safety of each child enrolled. Please review the CASTLE rules with your child.

Signature______Today’s date ______

(Over)

______

Child’s NameSerious Health Problem (please Note)

Emergency and Pick-up Information

Physician : Name:______work/cell/pager:______

Physician’s Address______City______

Medical Insurance:______Group/ID #______

Authorization

In case of an emergency, I authorize that my son/daughter be taken to the nearest medical center for emergency treatment and measures that are deemed necessary for the safety and protection of the child, at my expense. In the event of a life threatening allergic reaction, I authorize trained school personnel to give emergency treatment (Adrenalin via Epi-pen) to my child.

Parent/Guardian Signature______Date______

Names of Persons authorized to take child from the facility: (Parent/guardian must provide written authorization or make prior arrangement for child to be released to anyone not listed.)

Nam Name / Phon Phone Numbers / Rela Relationship

CASTLE closes at 6:00 PM. If the center has not heard from the parent, an alternative authorized person (above) will be called to pick up the child. If no one on the emergency form can be contacted CASTLE staff may: release my child to an unauthorized neighbor or friend, OR transport my child to the Valley of the Moon Children’s Shelter, 55 Pythian Rd., in Santa Rosa. 537-6350. The Sebastopol Police Department will be notified in this event.

Parent/Guardian Signature______Date______

Is there any person specifically not allowed to pick up your child?______