Prime Time Registration Form Phone Child's Name * Age * Age 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Birthday * Teacher's Name * Grade * Home Phone * Parent's Mailing Address * City * Zip Code * Parent's Email Address * In case of emergency, please list phone numbers where parents/guardians can be reached while your child is at Prime Time. Emergency Contact 1 * Emergency Contact 2 Relationship 1 * Relationship 2 Phone * Phone 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 * Name Name Name Relationship * Relationship Relationship Relationship Phone * Phone Phone Phone Medical Information Doctor Hospital Phone Check if you do not have a preferred doctor/hospital No Preference 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 food allergies? Yes No If yes, please list them Is your child currently under a Doctor's care, or taking any medications? Are there any specific fears, likes or dislikes that will help us care for your child? How does your child act when ill? Any additional information that will help us better care for your child: Please choose the care option your child will be using * Full Time $400 Morning $255 Afternoon $315 Flex $250 Prime Time has permission to photograph my child/family and use material in print and electronically for promotional material: * 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. By adding your name and checking "I agree", you are legally signing this form. Signature of Parent/Legal Guardian * Signature of Parent/Legal Guardian I Agree I Agree I Agree I Agree Date of Signature * Date of Signature
