Enrollment Record – Little Sprouts Learning Center

Contact Information

Date of Enrollment:

Child's Name^*

Nickname^*

Date of Birth^*

Allergies^*

Home Address^*

City^*

State^*

Zip^*

Best Contact Number:^*

Best Email Address^*

Mother or Guardian

Name^*

Mobile Number^*

Email^*

Home Address (if different)^*

City^*

State^*

Zip^*

Home Phone

Name of employment (mother/guardian)^*

Work Phone^*

Address of employment (mother/guardian)

Father or Guardian

Name^*

Mobile Number^*

Email^*

Home Address (if different)^*

City^*

State^*

Zip^*

Home Phone^*

Name of employment (father/guardian)^*

Work Phone^*

Address of employment (father/guardian)^*

Emergency Contacts

Emergency Contact #1 Name^*

Relationship to Child^*

Best Contact Number^*

Address^*

Emergency Contact #2 Name^*

Relationship to Child^*

Best Contact Number^*

Address^*

Persons authorized to pick up your child (Must Show Photo ID)

Pickup Authorized #1 Name^*

Relationship to Child^*

Best Contact Number^*

Address^*

Pickup Authorized #2 Name^*

Relationship to Child^*

Best Contact Number^*

Address^*

Medical Information

Primary Care Doctor Name/Practice^*

Phone Number^*

Address^*

Dentist Name/Practice^*

Phone Number^*

Address^*

Preferred Hospital (check one)

Memorial Hospital Main – 1400 Boulder St, (719) 365-5000Memorial Hospital North – 8890 Briargate Blvd, (719) 365-5000Penrose North Hospital – 2222 Nevada Ave, (719) 776-5000St. Francis Medical Canter – 6001 E. Woodmen Rd, (719) 570-1000Children’s Hospital, Briargate - 4090 Briargate Pkwy, (719) 305-1234Other (Name, Address, Phone:

Does your child have a health care plan?

if yes, the health care plan must be provided on or before the first day of care.

YesNo

Is your child fully immunized?

Completed immunization records must be provided on or before the first day of care.

Please bring us all updated records after receiving new immunizations.

YesNo

Chronic or Recurring Health History

Ear Infections^*

Insect Stings^*

Diabetes^*

Medication/Drugs^*

Heart Disease/Defect^*

Food^*

Convulsions/Seizures^*

Other^*

Asthma^*

Nosebleeds^*

Please list any other chronic conditions^*

Nature & dates of any surgeries or severe injuries^*

Is your child on any medications? ( if yes, please explain)^*

Does your child have any physical limitations? ( if yes, please explain)^*

Does your child have any dietary restrictions? ( if yes, please explain)^*

Please list any activities that you prefer your child NOT participate in^*

Authorization for Emergency Medical Care

I hereby give my permission to Little Sprouts Learning Center to call a doctor or emergency medical service and for the doctor, hospital or medical service to provide emergency medical or surgical care for my child,

It is understood that the childcare provider will make a conscientious effort to locate the parent/guardians and emergency contacts listed on the registration document before any action will be taken. If it is not possible to locate emergency contacts listed treatment will not be delayed. I/We will accept the expense of emergency transportation, medical or surgical treatment.

Upload

Date

Print Name^*

Date^*

Print Name^*

Date^*

Director Signature^*

Date^*

Contact Information (Classroom Copy)

Date of Enrollment:

Child's Name^*

Nickname^*

Date of Birth^*

Allergies^*

Mother or Guardian

Name^*

Home Phone^*

Cell Phone^*

Work Phone^*

Father or Guardian

Name^*

Home Phone^*

Cell Phone^*

Work Phone^*

Emergency Contacts

Emergency Contact #1 Name^*

Relationship to Child^*

Best Contact Number^*

Address^*

Emergency Contact #2 Name^*

Relationship to Child^*

Best Contact Number^*

Address^*

Persons authorized to pick up your child (Must Show Photo ID)

Pickup Authorized #1 Name^*

Relationship to Child^*

Best Contact Number^*

Address^*

Pickup Authorized #1 Name^*

Relationship to Child^*

Best Contact Number^*

Address^*