Child Care Program Registration

* = Required

Program Selection

Program*:

Child Information

Child's Name*:

Gender*:

Male Female

Age*:

Birthday*:

Parent Information

Parent's Name*:

Address*:

City* / State* / Zipcode*:

/ /

Email*:

Home Phone*:

Cell Phone:

Work Phone:

People Allowed to Pick-Up My Child

Name:

Phone:

Name:

Phone:

Name:

Phone:

Schedule

Emergency Contacts

If I cannot be reached in the event of an emergency, the following person is authorized to act in my behalf

Name:

Phone:

Name:

Phone:

Name:

Phone:

Child's Health Information

Is your child in good health*

Yes No (can he/she participate without any accommodations?)

Doctor's Name*:

Phone*:

Address*:

City* / State* / Zipcode*:

/ /

Child's Health History

Please provide as much information in this section as possible. All the selections are defaulted to "None" If any listing below applies to your children, please change this information accordingly. This will expedite your registration process when you come to our facility. Please indicate approximate date of occurrence to the following for all that may apply.

Ear Infections

Measles

Pennicillin

Poison Ivy

Asthma

Rheumatic Fever

German Measles

Chicken Pox

Insect Stings

Hay Fever

Convulsions

Mumps

Allergies

Operations or Serious Illness

Chronic or Recurring Illness

Please indicate dates of basic immunizations and most recent booster dates. It is also required that you provide us with a copy of the child's immunization records as mandated by state regulations.

DPT Series

German Measles

Measles (Live)

Tetanus Booster

Typhoid

Mumps Vaccines

Small Pox

Polio (sabin)

Tubeculin Test

Other

Misc Information

How Did You Hear About Us:

Notes:

Upon submission of this form, the parent or guardian is granting permission for the child to be transported by The Bounce Spot, LLC, personal vehicles, or by its contracted providers to and from school, day trips or extra-curricular activities. The health information indicated here is correct to the best of your knowledge. The child has permission to engage in all prescribed activities except if noted otherwise. In the event of an emergency, if a parent or guardian cannot be reached, permission is being granted to the physician selected be the Director to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for this child. Further authorization is given to the Director or his designee to provide over the counter medication to this child as necessary. The parent or guardian also agrees that in case of an injury to his or her child that is due to natural causes or by accident which involved no neglect by any staff that The Bounce Spot, LLC or the staff will not be held liable. The Bounce Spot reserves the right to change a trip location with out prior notice. The Bounce Spot, LLC, has permission to transport my child to and from activities as necessary.

*You will be required to sign this statement when you come to our facility.

Please be patient and wait for confirmation page of your submission
(do not press "Register" twice)
All information will remain private and confidential