Open Arms Child Development Center Enrollment

Child’s name: ______________________ Preferred name for class:____________

Date of Birth: __/__/__ Sex: Male or Female
Address:
__________________________________________________________________
__________________________________________________________________
Primary Care Physician: _____________________________________________
Please list any diagnosis that pertains to your child’s growth and
development:_______________________________________________________
__________________________________________________________________
Allergies (please list all, and explain severity):
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Medications (dosage, instructions, and please make sure the original label is on
medication):
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

*In the event of a medical emergency, we utilize the emergency medical services
and will have your child taken to the nearest hospital; You will be notified after
911 is called*
Sign here stating you agree: __________________________________________
 Parent Information:
Mother’s name: _______________________________ DOB __/__/__
Contact information:
__________________________________________________________
Address:
__________________________________________________________
Job & phone number:
_________________________________________________________

Father’s name: _________________________________ DOB __/__/__

Contact information:
__________________________________________________________
Address:
__________________________________________________________
Job & Phone number:
__________________________________________________________

Emergency Contact
We will go in order to this list if we are unable to get ahold of parents contact…

Name:_________________________________
Number:_______________________________
Relation to child: _______________________________

Name:_________________________________
Number:_______________________________
Relation to child: _______________________________
 Who can pick your child up (other than parents )
*Drivers License will be needed to pick child up if it is a new person*

Name: ____________________________________________________
Number: __________________ Relation to child: __________________
Driver’s license number: ______________________________________

Name: ____________________________________________________
Number: __________________ Relation to child: __________________
Driver’s license number: ______________________________________

Name: ____________________________________________________
Number: __________________ Relation to child: __________________
Driver’s license number: ______________________________________

If you feel like your child is at risk for somebody trying to pick him/her
up that is NOT allowed, please explain here:
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
 Media Consent Form:
I give permission for my child to be photographed for center’s website
(including center’s facebook), local newspaper, fundraising and/or
educational purposes…
Sign here: ________________________________________________
*Please attach a copy of immunization forms from
doctors office*