United Childcare and PreschoolRegistration Application Instructions:Please read this form in its entirety prior to completing it. You may need to gather some information you don’t have at hand. All required fields are marked with an asterisk (*). Please leave all fields blank that are followed by (OFFICE). Center/Room (OFFICE) Date Admitted (OFFICE) MM DD YYYY Starting Date (OFFICE) MM DD YYYY Fee (OFFICE) Name of Child * First Name Last Name Gender DOB * MM DD YYYY Place of Birth * Home Address * Preferred Phone * (###) ### #### EMERGENCY INFORMATION (other than parent/guardian) EMERGENCY CONTACT #1 * First Name Last Name Relationship * Address * Preferred Phone * (###) ### #### EMERGENCY CONTACT #2 * First Name Last Name Relationship * Address * Preferred Phone * (###) ### #### CHILD'S DOCTOR/CLINIC * Office Phone * (###) ### #### FAMILY INFORMATION PARENT/GUARDIAN #1 * First Name Last Name Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Preferred Phone * (###) ### #### Preferred Email * SSN * Age * Occupation * Employer * Days/Hours of Work * Business Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Business Phone * (###) ### #### Relationship Status Single Married Divorced Partnered PARENT/GUARDIAN #2 First Name Last Name Home Address Address 1 Address 2 City State/Province Zip/Postal Code Country Preferred Phone (###) ### #### Preferred Email SSN Age Occupation Employer Days/Hours of Work Business Address Address 1 Address 2 City State/Province Zip/Postal Code Country Business Phone (###) ### #### Relationship Status Single Married Divorced Partnered MEMBERS OF HOUSEHOLD: List all children in order of age and other members of the household living in your home. Name, relationship to child, present age. PHYSICAL INFORMATION Please describe your child's energy: * Describe motor ability and interest toward play: * Has your child had any serious illnesses, operations, accidents, or hospital experiences? * Does your child have any allergies? If so, please list and describe how to recognize an allergic reaction and how should we respond? * Is there anything unusual about your child's eating habits that you believe we should know before they eat at the center? * BATHROOM HABITS: Are they independent? Do they need assistance? * SLEEPING HABITS: Is your child used to taking daily naps? * How long does your child sleep for naps? * Does your child have a special toy or blanket for nap time? * How did you soothe your child when they were an infant? * PERSONALITY & EMOTIONAL BEHAVIOR How does your child respond to parents'/caregivers' absence? * Does your child have any fears? If so, of what? * What is used most effectively for discipline at home? * OTHER Is there any special information you feel the center should have which has not been included in previous questions? * Has your child had any previous preschool experience? * What would you like your child to experience at this center that was not present at the former center? PERMISSION FORM I hereby give my permission to United Childcare and Preschool, Inc. to: 1. Take my child to the outpatient department of a hospital or clinic in case of an accident or to contact my physician or hospital of my choice: * 2. Take my child on field trips as planned by the center's staff: * 3. UCP regularly posts pictures to the center's Instagram feed. This is a private account that can only be seen by UCP families and staff. If you would like your child to be included in these photos, provide your electronic signature below: PARENTAL/GUARDIAN AGREEMENT My child will attend United Childcare and Preschool, Inc. on the following days of the week: * Monday Tuesday Wednesday Thursday Friday Child will arrive at the center at approximately: * Child will leave at the center at approximately: * It will be paid by: * ANY CHANGES IN THE ABOVE AGREEMENT MUST BE APPROVED BY THE CENTER'S DIRECTOR. I have read and understand the policies as set forth in the parents handbook, and I WILL NOTIFY THE DIRECTOR, PERSONALLY, AT LEAST TWO WEEKS BEFORE MY CHILD IS WITHDRAWN FROM THE CENTER. IF I DO NOT GIVE A TWO-WEEK NOTICE, I WILL PAY THE FEE FOR THOSE TWO WEEKS. I agree to notify the director if there is a significant change in my income. I agree to be financially responsible for all changes and fees incurred at United Childcare and Preschool, Inc. for the care of my child or children. Parent/Guardian #1 Signature * Date Submitted * MM DD YYYY Parent/Guardian #2 Signature Date Submitted MM DD YYYY How did you hear about UPC? Friend Volunteer/Information Center Google Search Referral Other Name of referral: Thank you!
