3757 South Ponderosa Drive, Evergreen Colorado 80439

The Great Escape

Phone: 303-674-0448 Fax: 303-670-0129 Registration / Student Information Form Today’s Date______

Please fill in the following information. All sections of this form must be completed as per Co State Licensing

______/______Business Phone Cell Phone Student Name (First, Middle, Last) ______/______Signature of Parent / Legal Guardian ___ Current age Date of Birth Medical Information

______/______Physician Phone Number Home Telephone Number ______Physician’s Address ___Street Address ______/______Dentist Phone Number ___City, State, Zip Code ______Dentist’s Address ___Mailing Address if different than above ______Custodial Care ___Hospital of choice

Child is under the care of: ______Hospital Address _____Both parents ______Mother Only Allergies / Other critical medical information ______Other;______/______Name of Parent / Legal Guardian Relationship Persons Authorized to Pick Up/ Emergency Contacts These are individuals (other than those listed under ______/______custodial care) who have permission to pick up my ___ Employer Address child. Please list at least two as it is required by law.

______/______/______Business Phone Cell Phone ___Name Relationship

______/______/______Name of Parent / Legal Guardian ___Address Phone Number Relationship ______/______/______Name Relationship ___ Employer Address ______/______/______Address Phone Number ___Address Phone Number

______/______Name Relationship The Great Escape Registration / Student Information Form Continued Family Information

______Name of Student Student’s nickname or what he or she is usually called by

______Name and age(s) of sibling(s)

______Others in the household and relationship

Parent Permission

Medical Emergency

I, ______give my permission for a staff member of The Great Escape to contact a doctor for medical or surgical care for my child, ______should an emergency arise. I understand that a reasonable effort will be made to locate myself or my spouse, ______before any action is taken. If parental contact can not be made, we will accept the expense of the medical action taken.

Field Trips (This applies only to Preschool age children, individual filed trip notices will be given by classrooms)

I give consent for my child, ______to take part in field trips or excursions under the proper supervision of staff and parents of The Great Escape. I am aware that children will be traveling be either church van, private vehicle or walking. I will provide an appropriate car seat or booster seat for my child.

Sunscreen

I am aware that I need to apply sunscreen to my student prior to arrival at school. In the event that staff at The Great Escape see it necessary to apply or reapply sunscreen to my child, ______, I give consent for them to do so.

Child Abuse Reporting

Under the Child Protection Act of 1987 (CRS 19-3-301_ in the Colorado Children’s Code, child care center workers are required to report suspected child abuse or neglect. The law states that if a child care worker has reasonable cause to know or suspect that a child has been subjected to abuse or neglect or who has observed the child begin subjected to circumstances or conditions which would reasonable result in abuse or neglect shall immediately report or cause a report to be made of such act to the county department or local law enforcement agency. As a parent you will notified if a report has been made.

I have read and understand the above requirements concerning child abuse. I have read and understand the actions that will be taken with my child in case of medical emergency. I have read and understand that field trips may be taken if my child is in a preschool age class. ______Signature of Parent / Legal Guardian Today’s Date