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| REGISTRATION & CONSENT FORM BWH Backup Child Care Center | ||||||||||||||
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Please print out these pages and Fax to: 617.732.9544
Please complete For Employee: ID # _______________________________ Dept._________________________________ For Patient: Blue Card #:___________________________ Dept. _________________________________ Child(ren)'s First & Last Names: (Please list all
children in attendance) Employee E-mail address at work: ________________________________________________ Parent/Guardian: #1_____________________________Work Phone # __________________ Beeper #_____________________________________ Cell Phone: _____________________ Home Address:____________________ Apt. # _________ Home Phone # __________________ City_____________________ State________________ Zip Code Parent/Guardian: #2_____________________________Work Phone # __________________ Beeper #_____________________________________ Cell Phone: _____________________ Home Address:____________________ Apt. # _________ Home Phone # __________________ City_____________________ State________________ Zip Code_________________________
In the event that you leave your office or work area (i.e. lunch, meetings,
etc.), who can we call to get in touch with you? Generally this person
is a co-worker, administrative assistant, etc. Name:____________________________________ Work Phone # _________________________
Please list and verbally alert us to any allergies
your child may have to food, medication, etc. Allergies:_________________________________ Reactions:______________________________ Special Notes Regarding Meals:_____________________________________________________
Child’s Primary Language:_________________________________________________ Primary Language Keywords that apply to your child's age/stage of development: Milk __________________; Water _____________________; Juice __________________; Bottle _________________; Hungry ___________________; Tired _________________; Bathroom/Toilet ___________________; Diaper _______________; If there are any other primary language words you feel would be helpful, please include them here:
Please list times of naps, special comfort items, as well as your usual
routine for helping your child to sleep. _________________________________________________________________________________
Please list and verbally alert us to any medical or developmental condition that could require special care or attention. ________________________________________________________________________________________
Please tell us about your child's current care arrangements _____ Family child care _____ Center-based child care _____ Family menber at home _____ Nanny in home _____ Parent at home _____ Other. Please describe:
Comments:________________________________________________________________________
Any special instructions including ointments, wipes, powder, etc. Please note that in order for us to apply any topical's, you must first fill out a TOPICAL PERMISSION RELEASE. Please ask a teacher for this form. Diapering: Usual Routine:________________________________________________________________ Toileting: Usual Routine:________________________________________________________________
Is your child currently taking any medications?__________________ If so, Why?________________ Name of medication ____________________________________________________ Please note: Staff can only administer prescription medication when it is in the original prescription container and accompanied by a completed AUTHORIZATION FOR MEDICATION, which we provide for you. Please ask a staff member about our specific medication policies so we can best serve you and your child. It is essential to provide teachers with the above information at drop-off time, allowing them to offer the best possible care to your children. Please be sure to inform them of any unusual circumstances that might affect your child’s day. Thank you! PLEASE GIVE ALL MEDICATIONS TO A TEACHER - NEVER LEAVE MEDICATIONS IN YOUR CHILD'S BAG OR CUBBY
PARENT/GUARDIAN SIGNATURE:________________________________
NAME OF CHILD:________________________________________________________________ I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, if I cannot be reached, I hereby authorize the BWH Backup Child Care Center to transport my child by ambulance to the nearest emergency room or ____________________________ (name of hospital preferred) and to secure for my child the necessary medical treatment including anesthesia. I understand the teachers in the BWH Backup Child Care Center are trained in the basics of First Aid and I authorize them to give my child First Aid when appropriate. Is your child allergic to any medications? If so please state: Allergy: _____________________________________ Reaction: _________________________ PARENT/GUARDIAN SIGNATURE:________________________________ MEDICAL INSURANCE WITH:___________________________________________________ POLICY NUMBER:______________________________________________________________ DOCTOR'S NAME:______________________________________________________________ DOCTOR'S ADDRESS:___________________________________________________________ DOCTOR'S PHONE:_____________________________________________________________ CHILD'S BWH MEDICAL NUMBER: (if applicable) __________________________________ PARENT/GUARDIAN SIGNATURE:________________________________
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