Back to Forms List Registration Form West Branch Community Early Learning Center Child Registration Child's First Name * Last Name * Date of Birth * Sex Address * City, State, Zip * Parent/Guardian * Home Phone Cell Phone * Workplace Work Phone Cell Phone Provider Address, City, State, Zip (if different from child) Email * Cell provider allows us to send text alerts in the event of an emergency. Parent/Guardian Home Phone Cell Phone Workplace Work Phone Cell Phone Provider Address, City, State, Zip (if different from child) Email Physician * Address, City State, Zip * Phone * Dentist * Address, City State, Zip * Phone * Hospital * Address, City State, Zip * Phone * Unless indicated above WBELC will use the following providers:Jones Family Dentistry - 537 Westbury Drive, Iowa City IA 52245 (319) 338-9219Mercy Hospital - 500 E Market Street, Iowa City, IA 52245 (319) 339-0300Mercy Family Medicine West Branch - 206 Cookson Drive West Branch IA 52358 (319) 643-2516 Name of Insurance Subscriber's Name Plan ID# 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. Parent/Guardian * Date * Child's Weekly Attendance Schedule: * Mon Tues Wed Thur Fri 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) Emergency Contact 1 * Home Phone Cell Phone * Workplace Work Phone Relationship to child: * Emergency Contact 2 * Home Phone Cell Phone * Workplace Work Phone Relationship to child: * Emergency Contact 3 Home Phone Cell Phone Workplace Work Phone Relationship to child: Emergency Contact 4 Home Phone Cell Phone Workplace Work Phone Relationship to child: 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. Parent/Guardian * Date * Photography Release WBELC may take photographs/video tapings of our child for use in classroom projects, portfolios, and displays within the center. Parent/Guardian * Date * I/We give consent that WBELC may take photographs/video tapings of our child and I/We consent that the program may use the photographs/video tapes of our child in promoting the purpose of the Center. We recognize WBELC will not identify our child by name in the photographs used. We understand that no financial benefits from the use of the photographs/video tapes are obligated to be paid by us. DoDo Not Parent/Guardian * Date * Captcha If you are human, leave this field blank. Submit Δ
