apply-now - Harvest Child & Youth Development Center

Harvest Child and Youth Development Center Application Form

Child’s Name

Birth Date

Enrollment Date

Hours of Expected Attendance

Days of Expected Attendance

Child's Home Phone Number

POC

Private Pay

Child’s Home Address

Child’s Physician

Telephone

Physician Address

In EMERGENCIES... your child will be taken to the NEAREST HOSPITAL EMERGENCY ROOM. Your signature authorizes HCYDC to have your child transported to that hospital.

Signature of Parent/Guardian

Date

Parent Information

Mother’s Name

Home Phone

Mother’s Employer
Email

Mother’s Address (if different)

Mother’s Work Phone

Mother’s Cell Phone

Father’s Name

Home Phone

Father’s Employer
Email

Father’s Address (if different)

Father’s Work Phone

Father’s Cell Phone

When Parents/Guardians cannot be reached, please list at least two people who may be contacted to pick up your child in an emergency.

Name

Relationship to child
Phone

Name

Relationship to child
Phone

Name

Relationship to child
Phone

Please complete the following items, as appropriate, if your child has a condition(s) which might require medical care.

Medical Condition(s)

Medication(s) being taken by your child

Date of your child’s last Tetanus Shot

Allergies/Reactions, Food Allergies, etc.

Restrictions or modifications of your child’s activities, diet, or care

EMERGENCY MEDICAL INSTRUCTIONS

1. Signs/Symptoms to look for

2. If Signs/Symptoms appear, do this

3. To prevent incidents

Other special medical procedures that may be needed

Comments

I give permission to HCYDC to administer a non-prescription form of the medications listed below to my child in an emergency that I cannot be reached.

Signature of Parent/Guardian

Date

HCYDC Procedures for Illness/Injury

Staff will call home. If there is no answer—
Staff will then call the child’s Mother’s, Father’s, or Guardian’s cell phone, if this number has been given. If no answer—
Staff will call the Mother’s, Father’s, or Guardian’s place of employment. If there is no answer—
Staff will then call the emergency contacts that you have provided.
If no one can be reached, administration will call an ambulance to transport your child to the NEAREST HOSPITAL EMERGENCY ROOM.
Based upon the medical judgment of the attending physician, your child may be admitted at the NEAREST HOSPITAL.
The childcare will continue to call the PARENTS/GUARDIANS until someone is reached.

I have read the above procedures and understand them.

Date

Drop Off Times and Pick Up Times

My child

will be attending Harvest Child and Youth Development on the following days of the week:

Drop Off Times	Pick Up Times
Monday drop off time	Monday pick up time
Tuesday drop off time	Tuesday pick up time
Wednesday drop off time	Wednesday pick up time
Thursday drop off time	Thursday pick up time
Friday drop off time	Friday pick up time

acknowledge that the above times are when my child

will be attending HCYDC.

If for any reason these times change, I will fill out another form indicating when my child’s new drop off and pick up times will be.

I understand that the preschool day is from 8:30am - 3:30pm and that there are limited spots available for before/aftercare.

Parent / Guardian Signature

Date

Leave this field empty

Harvest Child & Youth Development Center

Harvest Child & Youth Development Center

Harvest Child and Youth Development Center Application Form

Parent Information

When Parents/Guardians cannot be reached, please list at least two people who may be contacted to pick up your child in an emergency.

Please complete the following items, as appropriate, if your child has a condition(s) which might require medical care.

EMERGENCY MEDICAL INSTRUCTIONS

HCYDC Procedures for Illness/Injury

Drop Off Times and Pick Up Times

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