Harmony Early ChildhoodEducationCenter
Registration Form
Today’s date: ______Starting date: ______Case #: ______
Child’s Name: ______Classroom: ______
(First Name) (Last Name)
Date of birth: ______Home Phone: ______
Gender: Boy _____Girl _____ Mom’s WorkPhone: ______
Email: ______Mom’s Cell Phone: ______
Email: ______Dad’s Work Phone: ______
Language(s) spoken: ______Dad’s Cell Phone: ______
Mother’s Name: ______Ethnicity: ______
(Or Guardian’s name)(First Name) (Last Name)
Street address: ______City: ______State: ______Zip code: ______
Father’s Name: ______Ethnicity: ______
(Or Guardian’s name)(First Name) (Last Name)
Street address: ______City: ______State: ______Zip code: ______
For Staff Use Only:
Arrival Time: ______Departure Time: ______Days: M. T. W. Th. F. Full dayPayment Type: Registration Fee:$______Ck#______Deposit: $______Ck#______
Monthly payment: $______DSHS monthly Co-Pay $______
Parent Handbook: ______Parental Responsibilities / Acknowledgement:______Security Code:______
Notes:
HEALTH SCREENING
Child’s Dentist: ______Phone Number: ______N/A Parent Initial _____
Address: ______
Primary Doctor: ______Phone Number: ______N/A Parent Initial _____
Address: ______
Date of Child’s Last Physical examination date: ______
Immunizations up to date: (Yes) ______(No) ______(Please ask staff if you need help)
1. Does your child presently have any health problems? (Yes)_____ (No)______
If yes, please explain: ______
2. Does your child have any chronic health conditions: (Yes) ______(No)______
If yes, please explain: ______
3. Does your child have sleep disturbances-nightmares, sleep-walking, waking up at night
or difficulty going to sleep? (Yes) _____ (No) _____
If yes, please explain: ______
4. Does your child have any special talent or hobbies that he/she enjoys? (Yes)______(No)______
If yes, please explain: ______
5. Have you left your child in daycare or with a babysitter before? (Yes) ______(No) ______
If yes, please explain: ______
6. Is your child toilet trained? (Yes) ______(No) ______
7. Is your child taking any medications? (Yes)______(No) ______What? ______
8. Is your child allergic to any food or drink? (Yes)______(No)______Please circle below:
--Milk Orange juice Apple juice Peanuts Other ______
9. Can your child have soy bean drink? (Yes) ______(No) ______
10. Does your child wear diapers? (Yes) ______(No) ______
11. Does your child have any allergies? (Yes) ______(No)______What? ______
Anything else you would like to share with us about your child:
Consent to Medical Care and Treatment of Minor Children
I hereby give permission that my child, ______, may be give emergency treatment by a
(Child’s Name)
qualified child care provider at Harmony Early Childhood Education Center, procedures to be performed for my child
by a licensed physician, health care provider, hospital or aid care attendant when deemed necessary or advisable by the
physician or aid car attendant to safeguard my child’s health. I waive my right of informed Consent to such treatment.
I also give my permission for my child to be transported by ambulance or aid car to an emergency center for treatment.
I, ______, under penalty of perjury under the laws of the State of Washington
(name of parent or Guardian’s name)
that the foregoing is true and correct. ______
(Parent or Guardian’s Signature) (Date)
Person to be contacted in an emergency pick up my child:
Please have the designated person(s)bring a picture ID when he or she comes to pick up your child.
Without the ID, we will not release your child.
1. Name: ______Phone: ______Relation to the child: ______
Address: ______
2. Name: ______Phone: ______Relation to the child: ______
Address: ______
( #3 need to be out of Washington State person for earthquake purpose, thank you!)
3. Name: ______Phone: ______Relation to the child: ______
Address: ______
Classroom Activity
I ______, do/do not wish my child______to participate in enrichment activity of Music and Dance. I understand there is an additional cost of $35.00 or $25.00 per month if I chose to have my child participate.
Permission to Photograph
I give permission for my child to be photographed or videotaped in scheduled Harmony Early Childhood Education Center activities. Such photographs and videotape may be used by Harmony Early Childhood Education Center for publicity or educational purposes. ______YES ______NO
Field Trips
I give Harmony Early Childhood Education Center permission to take my child to visit the parks around downtown Renton and along the Cedar River Trails. ______YES ______NO
Sun Block Lotion
I give Harmony Early Childhood Education Center permission to provide Banana Boat Baby Tear Free SPF 50 sun block to my child during the summer.
______YES ______NO
Parent or Guardian’s Signature: ______Date: ______
First day of school Check List
First of School: ______Password to Enter Harmony: ______
Parents need toProvide: / Item from Parents / Parent’s checking list
1. / A pair of clean indoor shoes / Please show your child where to put her belongings (cloth,cup,toothbrush and Shoes).
2. / Complete change of clothes, please includessocks and underwear. / Please put them all in one ZIPPlastic Bag and write your child’s name on it.
3. / Blanket / Please bring home to wash every month of last Friday. Please write down your child’s name.
Sheet must be purchased from Harmony ECE $12.00 additional charge (one time)
Clear Zip Bag (example) $2.00
4. / 1 4x6 child or family picture / For cubby use.
5. / Diapers or pull ups / At least one week supply.
6. / 1 boxes of Kleenex (tissue paper with location, for classroom use only) / We will ask parents regularly to bring the Kleenex; it will depend on how often childrenwill use them.
7. / 2 Boxes of Wipes if wearing diapers or pull ups / 1 box will be used for out door or classroom activity. We will ask parents regularly to bring the wipes and gloves; it will depend on how often the child uses it.
2 Box of gloves if wearing diapers or pull ups
8. / Purchase gloves at Harmony for your convenience. (100 gloves for $10.00) / $10.00 (100 gloveseach) will be charged to your next invoice if it is purchased from Harmony.
9. / 1 Box of wipe for Preschoolers / We will ask parents regularly to bring the wipe and gloves; it will depend on how often childrenwill use them.
1 Box of Gloves
10. / Toothbrush, kids toothpaste and Cup (Caterpillar and Butterfly class only) / Please write your child’s name on each item.
11. / We strongly encourage parents to label everything in permanent marker in order to identify lost items.
Harmony Conversation Log
Child’s Name: ______Parent’s Name: ______Tel: ______
Date of Birth: ______Today’s day: ______
Date / Regarding ofRegistration was given on ______by ______.
Spoke to DSHS: ______Case has approved from ______to ______units
Co-Pay is $______Starting ______the Co-pay will be ______. The case has been denied.
First day of School at Harmony is :______
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