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Enrollment Agreement

Completion of this agreement is required for enrollment. This form will enable us to better understand your child and meet his/her needs. Much of the information requested is necessary to comply with state child care licensing regulations.


Enrollment Information


Child's Information


Family Information


Child Emergency Contact and Release Information

Do not include parents/guardians/sponsors

Please notify the center if an Emergency Release Contact will pick up your child on a given day. (For the safety of your child, we request that all authorized pick up persons with whom staff is not familiar provide a photo ID at the time of pick up.)

Person #1

Person #2

Person #3

The persons designated in this section will be contacted by us if you cannot be reached in the event of a medical or other emergency. Our staff will only release your child to you or to those persons listed above. If you want a person who is not identified above to pick up your child, you must notify our staff in advance, in writing. Your child will not be released without prior authorization.


Medical Information


Child's Medical & Developmental History




If yes, please email care instructions from your physician to info@dreamacademymonroe.com


If yes, please email care instructions from your physician to info@dreamacademymonroe.com


If yes, please email care instructions from your physician to info@dreamacademymonroe.com









Illness History

Please check all that apply

Please email care instructions from your physician for any of these illnesses to info@dreamacademymonroe.com

Disease History

Please check all that apply

Allergies

Please list each allergy AND the reaction experienced

Please email care instructions from your physician for any life-threatening allergies to info@dreamacademymonroe.com

Miscellaneous Screenings and Tests

Please check all that apply


Child's Medical Care Provider


Child’s Insurance Provider


Child’s Immunization History

Please email a copy of your child’s immunization records to info@dreamacademymonroe.com

Below is a list of immunizations that your child may have received. Please enter the date of each immunization. These immunizations are required by our state.


Additional Medical Policies


Emergency Medical Authorization & Consent





To sign this document, please type your name in the box below.