Parent Name *

First Name

Last Name

Parent DOB

MM

DD

YYYY

Phone *

(###)

###

####

Start Time *

Hour

Minute

Second

AM PM

End Time *

Hour

Minute

Second

AM PM

Child Name *

First Name

Last Name

Child Gender

M

F

Child DOB *

MM

DD

YYYY

Disability

*Individual Family Service Plan is a plan for special services for young children with developmental delays.

My child has a disability

My child has an IFSP

My child is receiving mental health treatment

Child's Doctor *

First Name

Last Name

Last Physical Exam *

MM

DD

YYYY

Child's Dentist *

First Name

Last Name

Last Dental Exam

MM

DD

YYYY

Emergency Contact 1 *

First Name

Last Name

Emergency Phone 1 *

(###)

###

####

Emergency Contact 2 *

First Name

Last Name

Emergency Phone 2 *

(###)

###

####

What kind of reaction does your child have when your child eats the food listed in previous question?

Rash

Swelling

Diarrhea

Difficulty Breathing

Life Threatening

Other

PERMISSION FOR ACCESS TO MEDICAL &/OR ASSESSMENT *

I grant permission for Teaching Staff and other regulatory staff to have access to Medical &/or Assessment information as needed to better serve my child or improve the effectiveness of the childcare center. Any other access to these records will require a separate written consent from me.

I agree.

I disagree.

PERMISSION FOR EMERGENCY PROCEDURE *

I grant permission to take whatever emergency, (e.g., first aid, disaster evacuation) measures as judged necessary for the care and protection of my child while under the supervision of the school as warranted. Teachers treat minor accidents, such as scrapes or bumps we will apply first aid using universal precaution It is understood that in some medical situations, the staff will need to contact the local emergency resource before the parent, child's physician, and/or other adult acting on the parent's behalf. In case of a medical emergency, I understand that my child will be transported to an appropriate medical facility by the local emergency unit for treatment if the local emergency resource (Police, Rescue Squad) deem it necessary.

I agree.

I disagree.

PERMISSION FOR ACTIVITIES/WALK *

I grant permission for my child to use all of the play equipment and participate in all of the activities of the school, unless exceptions are noted in next question. I grant permission for my child to leave the school premises under the supervision of a staff member for neighborhood walks, i.e., Edgewood Park vicinity

I agree.

I disagree.

PERMISSION FOR PICTURES *

I grant permission for my child to be included in evaluations and photographs/videos connected with the school’s programs.

I agree.

I disagree.

ALTERNATIVE CARE PLAN *

I have received a copy of the calendar and know when the center will be closed

I agree.

I disagree.

PERMISSION TO SHARE CONTACT INFORMATION WITH OTHER FAMILIES *

I grant permission for Morning Glory to share phone numbers and emails with other families for the purpose of connecting for social events including parties and playdates etc. (Morning Glory does not distribute invitations at school.)

I agree.

I disagree.

Certification of Application *

This certifies that all information provided on this application and attachments is accurate and truthful. (Type name of parent.)

First Name

Last Name

Application Date *

MM

DD

YYYY