Highbridge Bronx - Need Child Care? Register Today

Family Day Care Xp-

Child Care Day Care

If you have decided to enroll your child, please fill out form for speedy processing of paperwork. Childs name,age,sex,date of birth,name of person applying,relationship to child,email address,and contact number must be completed for registration to be submitted.

Child's Registration Form

Childs Full Name:

Childs Sex:

Childs Age:

Childs Home Address:

City, State, Zip:

Childs Date of Birth:

Childs Home Phone #:

Childs Country/State of Birth:

Name of person applying for child:

Relationship:

Home Phone #:

Daytime Phone#:

Email Address:

Address of Person listed above if different from child:

City, State, Zip:

Job/School Name:

Job/School Address:

Job/School Phone:

Please Provide Income:

Per

<<SPACE>>

Alternate Child Pick Up Information

Escort Information 1

Escort Name:

Escort Address:

Escort City, state Zip:

Escort Phone Number:

Escort Phone Type:

<<SPACE>>

Escort Information 2

Escort Name:

Escort Address:

Escort City, state Zip:

Escort Phone Number:

Escort Phone Type:

<<SPACE>>

Escort Information 3

Escort Name:

Escort Address:

Escort City, state Zip:

Escort Phone Number:

Escort Phone Type:

<<SPACE>>

Escort Information 4

Escort Name

Escort Address:

Escort City, state Zip:

Escort Phone Number:

Escort Phone Type:

<<SPACE>>

Food And Snacks

Food is offered...

Food is offered to your child but they are not forced to eat it. Parent/Guardians will be notified immediately if your child is not eating. The aim of the program is to serve nutritious and well balanced meals and snacks, please list some foods that fall in this category that your child enjoys to help establish a nutritious but Satisfying menu:

Satisfying menu

<<SPACE>>

Special Health conditions 1

Condition

Age It began

Treatment/Medications

<<SPACE>>

Special Health conditions 2

Condition

Age It began

Treatment/Medications

<<SPACE>>

Special Health conditions 3

Condition

Age It began

Treatment/Medications

<<SPACE>>

Special Health conditions 4

Condition

Age It began

Treatment/Medications

<<SPACE>>

Special Health conditions 5

Condition

Age It began

Treatment/Medications

<<SPACE>>

Has child ever been operated on?

If yes Explain:

Has child ever had a serious accident(borken bone, head injury, fall, poisoning)?

If yes Explain:

Has child ever had a serious illness?

If yes Explain:

Does your child have any allergies?

If so what is your child allergic to?

<<SPACE>>

Significant family history

List all that apply (Sickle Cell, Diabetes, Convulsive Disorder, Allergies(specify),Other(specify), Heart Disease, hypertension, Tuberculosis, Vision, Hearing):

Significant Family History (Specify)

<<SPACE>>

Child's Source of Medical Care/Primary Care Physician's Name and Address:

Physician's Telephone:

<<SPACE>>

Child's Sources of Dental Care/Dentist's Name and Address:

Telephone:

<<SPACE>>

Name Of Medical Care Facility/Hospital and Address:

Telephone:

<<SPACE>>

Emergency Data 1

Relationship

Contact Name

Telephone # during child care

Type

Other Telephone #

Type

<<SPACE>>

Emergency Data 2

Relationship

Contact Name

Telephone # during child care

Type

Other Telephone #

Type

<<SPACE>>

Emergency Data 3

Relationship

Contact Name

Telephone # during child care

Type

Other Telephone #

Type

<<SPACE>>

Emergency Data 4

Relationship

Contact Name

Telephone # during child care

Type

Other Telephone #

Type

<<SPACE>>

Agreements:

I consent for my child to take part in neighborhood trips(i.e. library, park, and playground) away from the facility under proper supervision:

In case of accident or injury, I authorize any and all emergency medical, dental, and/or surgical care and hospitalization advised by the physicians, surgeon or hospital (listed on above) necessary for the proper health and well-being and of my child:

I have provided information on my childs special needs (Allergies, Diet, Disabilities, and/or Medical information) to the Provider, as may be necessary to assist the facility in properly caring for my child in case of an emergency:

I agree to review and update this information when ever a change occurs and at least once every six months:

Family Day Care Xp-

Child Care Day Care

Child's Registration Form

Childs Full Name:

Childs Sex:

City, State, Zip:

Childs Home Phone #:

Childs Age:

Childs Home Address:

Childs Date of Birth:

Childs Country/State of Birth:

Name of person applying for child:

Relationship:

Daytime Phone#:

Home Phone #:

Address of Person listed above if different from child:

City, State, Zip:

Email Address:

Job/School Name:

Job/School Address:

Job/School Phone:

Please Provide Income:

Per

Alternate Pick Up 1 Name:

Alternate Pick Up 1 Address:

Alternate Pick Up 1 City, state Zip:

Alternate Pick Up 1 Phone Number:

Alternate Pick Up 1 Phone Type:

Alternate Pick Up 2 Name

Alternate Pick Up 2 Address:

Alternate Pick Up 2 Phone Number:

Alternate Pick Up 2 Phone Type:

Alternate Pick Up 3 Name:

Alternate Pick Up 2 City, state Zip:

Alternate Pick Up 3 Address:

Alternate Pick Up 3 City, state Zip:

Alternate Pick Up 3 Phone Number:

Alternate Pick Up 3 Phone Type:

Alternate Pick Up 4 Name

Alternate Pick Up 4 Address:

Alternate Pick Up 4 City, state Zip:

Alternate Pick Up 4 Phone Number:

Alternate Pick Up 4 Phone Type:

Special Health conditions 1

Age conditions 1 began

conditions 1 Treatment/Medications

Special Health conditions 2

Age conditions 2 began

conditions 2 Treatment/Medications

Special Health conditions 3

Age conditions 3 began

conditions 3 Treatment/Medications

Special Health conditions 4

Age Special Health conditions 4 began

Special Health conditions 4 Treatment/Medications

Special Health conditions 5 Condition

Special Health conditions 5 Age It began

Special Health conditions 5 Treatment/Medications

Has child ever been operated on?

If yes Explain:

Has child ever had a serious accident(borken bone, head injury, fall, poisoning)?

If yes Explain:

Has child ever had a serious illness?

If yes Explain:

Does your child have any allergies?

If so what is your child allergic to?

SIGNIFICANT FAMILY HISTORY- List all that apply (Sickle Cell, Diabetes, Convulsive Disorder, Allergies(specify),Other(specify), Heart Disease, hypertension, Tuberculosis, Vision, Hearing):

Child's Source of Medical Care/Primary Care Physician's Name and Address:

Physician's Telephone:

Child's Sources of Dental Care/Dentist's Name and Address:

Child's Sources of Dental Care/Dentist's Name, Address And Telephone:

Name Of Medical Care Facility/Hospital Address:

Name Of Medical Care Facility/Hospital Telephone:

Emergency Contact 1 Name

Emergency Contact 1 Relationship

Emergency Contact 1 Telephone # during child care

Emergency Contact 1 Type

Emergency Contact 1 Other Telephone #

Emergency Contact 1 Phone Type

Emergency Contact 2 Name

Emergency Contact 2 Relationship

Emergency Contact 2 Telephone # during child care

Emergency Contact 2 Type

Emergency Contact 2 Other Telephone #

Emergency Contact 2 Type

Emergency Data 3 Contact Name

Emergency Data 3 Relationship

Emergency Data 3 Telephone # during child care

Emergency Data 3 Type

Emergency Data 3 Other Telephone #

Emergency Data 3 Type

Emergency Data 4 Contact Name

Emergency Data 4 Relationship

Emergency Data 4 Telephone # during child care

Emergency Data 4 Type

Emergency Data 4 Other Telephone #

Emergency Data 4 Type

I consent for my child to take part in neighborhood trips(i.e. library, park, and playground) away from the facility under proper supervision:

I agree to review and update this information when ever a change occurs and at least once every six months:

New Field: