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CHILDREN...OUR MOST VALUABLE RESOURCE. KEEPING THEM SAFE IS OUR FIRST PRIORITY.
The People's Choice Award for best daycare in the Arkansas Valley for the years 2001,2003,2004,2005,2006
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First Impressions Learning Center
Child’s Name:_________________________________ Birth date:____/____/____ Preferred Name:_________________________ Male____Female____ Address:______________________________________________________ Parents are: Married____ Separated____ Divorced____ Child lives with: Father___Mother___Stepfather___Stepmother___Guardian___ Father/Stepfather:_______________________ Home Phone:____________ Where Employed: ________________________ Phone: _______________ Social Security Number: _____-_____-_____ Mother/Stepmother:______________________ Home Phone:___________ Where Employed:________________________ Phone:_________________ Social Security Number: _____-_____-_____ If child lives with guardian, please list name of guardian and relationship to child. Name:__________________________________ Relationship:___________ Social Security Number: _____-_____-_____ Who may be called that will assume responsibility for your child in case of emergency Name:__________________________________ Phone:________________ Please list names of persons you authorize to pick up your child Name:_______________________Name:________________________ Name: ______________________ Name: ________________________ List names and addresses of persons NOT AUTHORIZED to pick up your child. Allergies to food/medicine:______________________________________________________ Child’s Doctor and Phone:_______________________________________________________ Child’s Dentist and Phone:______________________________________________________ First Impressions Learning Center HEALTH RECORD PARENTS: Please fill out as much as possible and return. Child’s Name: _____________________________Birthdate___/___/___Male___Female___ Address: ____________________________________________________________________ Mother’s Name: _________________________ Father’s Name: _______________________ Check any illness child has had: Measles___ German Measles___ Mumps___ Other (explain) _______________________________________________________________ Allergies (food or medicine): ____________________________________________________ Contact with Tuberculosis: Yes ___ No ___ If Tuberculosis test given: Date: ___________________ List any special problems, accidents, or surgical procedures: _____________________________ Physical findings (including vision and hearing if applicable): ____________________________ List any visible birthmarks or scars: _________________________________________________ Other recommendations: _________________________________________________________ Signature of doctor or nurse: _________________________________
Child’s Name: ___________________________________ Birthdate: ___/___/___ This form will remain in effect from the signature date until a new contract is signed To change your contract, you must complete a NEW contract with the director in the office. Hourly slot: 2 hours or less $2.50 per hour Part-time slot: 2:01 hours to 4:59 hours $8.80 Full-time slot: 5:00 hours or more $16.00 (under 2 years old) $15.00 (over 2 years old) Monday: _____________________ _____________________________________________ _____/_____/_____ PERMISSION SLIP CHILD’S NAME: _____________________________________________ PARENT(S) / GUARDIAN(S) NAME(S): _____________________________________________ PLEASE READ EACH PARAGRAPH, INITIAL ON THE LINE, AND SIGN AT THE BOTTOM. *In case of emergency, I hereby give permission to First Impressions *Parents/Guardians are responsible for all medical/dental costs including *I hereby give permission to the First Impressions Learning Center *I hereby give permission to First Impressions Learning Center *I hereby give permission to the First Impressions Learning Center *I hereby give permission to First Impressions Learning Center Occasionally there are accidents, incidents, or health issues that require a decision _______________________________________________ ____/_____/____ Parent(s)/Guardian(s) Signature Date Formula Decision Form Childcare Center’s Name : _____________________________________________ Infant’s Name : __________________________________ Date of Birth _____/_____/_____ Infants being fed formula must have this form completed and on file before If the infant is being fed breast milk, this form is not required. Our center participates in the Child and Adult Care Food Program (CACFP). In order In our center, the iron-fortified formulas are available at no charge to you are : (Milk Based )_______________________________________________________
(Soy Based )________________________________________________________ You as a parent or guardian may decline the formula(s) provided by our center and supply Please choose one of these options and fill out the following information: When meals are served to my infant, effective ______________________________ ___ Yes , I accept the formula supplied by your childcare center as the iron-fortified ___ No, I decline your childcare center’s choice of formulas. I will purchase and _____________________________ __________________________ Parent/Guardian’s Complete Name (print) Parent/Guardian’s Signature _______________________________________
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