Inc. Today’s Date______

Registration Form & Waiting List Application Child’s Name______ Male  Female Birth date______Date you would like to begin ______Siblings interested in enrolling ______(One form required for each child enrolling)

Schedule Please list drop off and pick up times next to the appropriate days below. Please be realistic in your times, we do arrange staffing and billing accordingly. (Any time over 10 hours is billed hourly) _____to ______to ______to ______to ______to_____ Monday Tuesday Wednesday Thursday Friday

Family Information ______Mother’s Name Home Address City Zip

______Mom’s Day time work place City Day time Phone Cell / other phone#

______Home Phone Mom’s email address Day time Phone Cell / other phone# ______Father’s Name Home Address (If different from Mom’s) City Zip

______Father’s Day time work place City Daytime Phone Cell/ other phone #

______Home Phone (If different from Mom’s) Dad’s email address Day time Phone Cell / other phone#

Drivers License # ______Exp. Date______Mom or Dad ( Please circle one) Emergency Contacts: Person to be contacted in an emergency ______If parents are not available Name Relationship Day Phone Number ______Day time Address

Other Authorized escort besides ______Those listed above Name Relationship Day Phone Number ______(Drivers license required Daytime Address in order to release child) ______Name Relationship Day Phone Number ______Daytime Address

Forms to turn in: □ Emergency Medical Release □ Health History and Emergency Care Plan □ Child Health Report (signed by physician) □ Day Care Immunization Record □ Intake form (children under 2 yrs old) □Parent Manual Review Optional Information: The following information is optional; but we appreciate your answers as it helps us to know you and your children a little bit better. Thank you for taking the time to help us with this.

Family Marital Status: Single Married Divorced Separated Widowed

Who will typically be the person dropping off your child? ______Picking up? ______

Do you have a family pet? If so, what______Name:______

Please list any siblings ______Name age name age Is there anyone, other than your immediate family, living at your home? ______Name Relation

Child’s current toilet training status: Well Trained Occasional Accidents Working On it not ready yet Please explain any methods you are currently using at home if you are working on it ______

Has your child ever been asked to leave another childcare setting? ______Yes _____No If yes, please explain ______

Have you come from another center? ____yes _____no If yes, please explain why you decided to leave that center to come to Range Line Preschool and Childcare ______

How and when does your child typically sleep? Does you child have a favorite stuffed toy or blanket he/she needs for nap times? ______

Does your child have ADD, ADHD or any tendencies towards it (or any other special needs) ? ______no ______yes, please explain: ______

Any other information you feel would be helpful for us to know regarding your child and or family? ______

How did you hear about us? ______

This section must be read; all boxes checked and signed below in order to enroll: I/we give Range Line Preschool and Childcare, Inc. permission for my child to participate in any walks, field trips (walking or transported), or outings sponsored and supervised by RLPC (RLPC will send home individual field trip permission forms for all transported fieldtrips).  I currently have health insurance covering my child and I understand it is my responsibility to cover the cost of any injury to my child unless caused by the negligence of a staff member at RLPC.  I agree to complete and return to RLPC the “Authorization for Treatment of Minor Children in the Absence of Parent” form thus giving my consent for emergency medical care or treatment to be used if I cannot be reached.  I have read, understand and agree to abide by RLPC fee schedule policies (given to families), the RLPC Family Handbook (given to families), and the summary of Wisconsin Rules for Licensing Childcare Centers (a located near the front desk for your review) .  A written termination notice is required two weeks prior to my child’s last day during which, I will be responsible for the full tuition fee.  I/we give RLPC permission to apply any ointment, lotion or spray that I provide, to my child as needed.  I understand that having my name on the waiting list will not guarantee my child enrollment. When space opens up, the center director will contact me to finalize a start day. At this time, the family enrollment fee along with the first week’s tuition paid in full will secure my child’s place.  I have been informed of the number of pets in the center and their degree of contact with the enrolled children Note if pets are added after a child enrolls, parents will be notified in writing prior to the pet’s addition to the center

Legal Guardian Signature: ______Date______

Legal Guardian Signature: ______Date______