Registration Form

Registration Form

West Branch Community Early Learning Center Child Registration

Cell provider allows us to send text alerts in the event of an emergency.

Unless indicated above WBELC will use the following providers:
Jones Family Dentistry - 537 Westbury Drive, Iowa City IA 52245 (319) 338-9219
Mercy Hospital - 500 E Market Street, Iowa City, IA 52245 (319) 339-0300
Mercy Family Medicine West Branch - 206 Cookson Drive West Branch IA 52358 (319) 643-2516

Special Conditions, Disabilities, Allergies, or Medical Information for Emergency Situations


Name any concern that might require special care. Expect and give permission for the center to post the name, photo, and type of health concern the child has that might require an emergency response, ie: food allergy, severe reaction to insect stings, asthma, blood sugar condition, medication problem.

I give consent for my child to participate on group walks. Fieldtrips in a car, van, or public transportation will require a separate permission statement.

Child's Weekly Attendance Schedule:

Emergency Contacts (a minimum of 2 required)

(Individuals to whom a child may be released if parent/legal guardian is unavailable or who may be contacted in an emergency)

Parent/Legal Guardian Consent


As parent/legal guardian, I give consent for my child to receive first aid from facility staff and, if necessary, to be transported to receive medical/surgical/dental care in an emergency. I understand that I will be responsible for all charges not covered by insurance. The information on this form may be shared with staff members who are responsible for supervision of my child. I understand that I will be asked to sign separate consent forms for medication administration, release of confidential information, field trips, and special program activities.

For child pickup and emergencies: If I am unavailable for a routine or emergency pickup of a child, I give consent for the emergency contact person listed previously to act on my behalf until I am available. I understand that a photo ID will be requested by staff members to be sure that the person picking up my child is a person who is listed on this form as a person who is authorized to do so. I agree to review and update this information whenever a change occurs and at least annually.

Photography Release


WBELC may take photographs/video tapings of our child for use in classroom projects, portfolios, and displays within the center.