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REGISTRATION FORM MGH Backup Child Care Center

Please print out these pages and fax to: 617.724.7171

MGH BACKUP CHILDCARE CENTER - Warren Lobby
REGISTRATION FORM
For The Safety Of Your Child(ren) It Is Imperative To Thoroughly Complete This Document

Please complete:  

For Employee: ID # _______________________________ Dept._________________________________

For Patient: Blue Card #:___________________________ Dept. _________________________________

Child(ren)'s First & Last Names: (Please list all children in attendance)
1. ___________________________________________     DOB: ___-___-___   Gender: ____
2. ___________________________________________     DOB: ___-___-___   Gender: ____
3. ___________________________________________     DOB: ___-___-___   Gender: ____

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_________________________

 

 

CONTACT INDIVIDUAL

In the event you leave your office (i.e. lunch time, meetings, etc.), who can we call to get in touch with you? Generally this person is a co-worker, secretary, etc.
Name:____________________________________ Work Phone # _________________________

ALLERGIES / EATING SCHEDULE

Please list and verbally alert us to any allergies your child may have to food, medication, etc.
Please check here if there are NO KNOWN ALLERGIES _______

Allergies:_________________________________ Reactions:______________________________

Special Notes Regarding Meals:_____________________________________________________

SLEEP SCHEDULE

Please list times of naps, special comfort items, as well as your usual routine for helping your child to sleep. ____________________________________________________________________________
_________________________________________________________________________________

MEDICAL OR DEVELOPMENTAL CONDITIONS

Please list and verbally alert us to any medical or developmental condition that could require special care or attention.

__________________________________________________________________________________

__________________________________________________________________________________

ANY OTHER INFORMATION WE SHOULD KNOW ABOUT YOUR CHILD(REN) TO MAKE HIS/HER STAY MORE ENJOYABLE

Comments:________________________________________________________________________

DIAPERING / TOILETING

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:________________________________________________________________

 

MEDICATION

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

EMERGENCY RELEASE INDIVIDUALS-OTHER THAN PARENT/GUARDIANS

I hereby authorize the MGH Backup Child Care Center to release my child to the following persons.

#1 Name:________________________________ Relationship to child:____________________

Address:_________________________ City:_______________ State: ______ Zip:_________

Day Telephone:___________________________ Evening Telephone:____________________

Cell Phone: ______________________________


#2 Name:________________________________ Relationship to child:____________________

Address:_________________________ City:_______________ State: ______ Zip:_________

Day Telephone:___________________________ Evening Telephone:____________________

Cell Phone: ______________________________

PARENT/GUARDIAN SIGNATURE:________________________________
                                               PRINT:________________________________
                                                DATE:________________________________