REGISTRATION DOCUMENTS

Fill the form Registration

Child #1 Name*

DOB*

Gender*

Child #2 Name

DOB

Gender*

Parent / Guardian*

Phone: (c)*

Phone: (w)*

Place of Employment

Address (Same as child)

Parent / Guardian

Phone: (c)

Phone: (w)

Place of Employment

Address (Same as child)

Physician

Phone

Address

Preferred Hospital

EMERGENCY CARE AUTHORIZATION
I authorize Haymarket Children's Academy to provide all emergency measures for the care and protection of my child while under their supervision. In case of a medical emergency, I understand that my child may be transported to an appropriate medical facility by the local emergency unit for treatment. It is understood that in some medical situations, the staff will need to contact the local emergency resource before the parent, child's physician, and/or adult acting on the parent's behalf.

Name*

Date

MEDICATION AUTHORIZATION
I authorize an employee at Haymarket Children's Academy who possesses the necessary certification (i.e. MAT trained) to administer medication as ordered by my child's physician either verbally or in writing while my child is being cared for at Haymarket Children's Academy.

Name*

Date

PHOTOGRAPH AND VIDEO AUTHORIZATION
I authorize the Haymarket Children's Academy to use any photograph or video of my child on its Social Media (Facebook and Website)

Name

Marketing Materials

EMERGENCY CONTACTS
Two People (other than the parents) to be contacted in case of emergency and authorized to pick up the child:

Name*

Phone

Address

Name*

Phone

Address

Other People Authorized for Pickup

Adminsteration

Class

Date of Enrollment*

Reg. Paid

REGISTRATION DOCUMENTS

Fill the form Registration

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