- MGLite

Child Enrollment Form

Emergency Medical Care Authorization & Consents

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Submission Details

Date of Application

Child's Information

Child's Full Name

Date of Birth

Home Phone

Home Address

Guardian 1

Same Address

Full Name

Home Address

Employer Name & Address

Guardian 2

Same Address

Full Name

Home Address

Employer Name & Address

Medical & Emergency Authorization

Physician Name & Phone

Dentist Name & Phone

Last Tetanus

Insurance Carrier

Insurance ID #

Preferred Hospital

Known Allergies / Special Needs

I give consent for First Aid/CPR and transport to the nearest hospital in a medical emergency. I understand I am responsible for medical fees. I authorize staff to contact the physician/dentist if I cannot be reached.

Requested Care Schedule

Mon

Tue

Wed

Thu

Fri

Authorized Pickups

Emergency Backup Contacts

Permissions

Permission to use all play equipment/activities.

Permission for supervised neighborhood walks.

Permission for photos/videos in school programs.

Permission for staff to access Medical/Assessment info.

Permission for emergency medical transport for my child if deemed necessary.

I understand that staff will contact 911 before parents/physicians in life-threatening situations.

Share phone/email with other families for social events.

Center Policies & Mandatory Agreements

I consent to Developmental Screenings.

I acknowledge the Zero Tolerance Policy.

I acknowledge the Challenging Behaviors Policy.

I acknowledge the Parent Handbook and the Orientation Checklist.

I have received a copy of the center calendar.

Digital Signature

By signing below, you agree that all information provided is accurate and you consent to all checked items above.

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