Prime Time Online Registration Child's Name Age Birthday Cell Phone Email Address Parent's Mailing Address City Zip Code In case of emergency, please list phone numbers where parents/guardians can be reached while your child is at Prime Time. Emergency Contact 1 Relationship Phone Phone Emergency Contact 2 Relationship Phone Phone Individuals picking your child up must be authorized in writing. Phone calls will not work in accordance with State law. Please list individuals authorized to pick up your child, including yourself. Name (parent) Relationship Phone Name (parent) Relationship Phone Name Relationship Phone Name Relationship Phone Medical Information Doctor Hospital Phone Check if you do not have a preferred doctor/hospital Health Insurance Policy Number Date of Last Exam Date of last Tetanus Shot (DPT) Dentist Name Date of last Dental Exam Does your child have any drug allergies? Yes No If yes, please list them Does your child have any specific health problems or food allergies? Yes No If yes, please list them Is your child currently under a Doctor’s care, or taking any medications? Yes No If yes, please list them Are there any specific fears, likes or dislikes that will help us care for your child? Yes No If yes, please list them How does your child act when ill? Any additional information that will help us better care for your child: Please check location: PT @ IPC PT @ Lowell Please circle the care option your child will be using: Full Time (3-5 days) $540 Part Time (1-2 days) $325 Mornings $350 Afternoons $400 Prime Time has permission to photograph/video my child/family and use material in print and electronically for promotional material and training purposes: Yes No Prime Time has my permission to walk my child to and from school and on walking field trips to local parks and attractions: Yes No I authorize Prime Time to provide care for my child. In the event my child is injured or becomes seriously ill and I cannot be reached, I authorize the Prime Time staff to seek medical attention and I authorize any and all hospitalization, medical, dental and/or surgical treatment deemed advisable by the circumstances. I understand any of the foregoing care will be at my expense. Checking this box means you understand and agree to Prime Time's terms and conditions. Date Submit
