Kids of the Kingdom Child Development Center

Organization Name Kids of the Kingdom Lutheran Child Dev. Center		Director's Name Pam Clay
Child's Name		Birthdate	Child's Home Telephone No.

Child's Address

Date of Admission		Date of Withdrawal	Hours and days child will be in care

Parent or Guardian's Name		Address (if different than child's address)

List telephone numbers where parent/guardian may be reached while child will be in care:	Mother's Telephone No.	Father's Telephone No.	Guardian's Telepohone No.

Give the name, address and phone number of person to call in case of emergency if parents/ guardian cannot be reached:			Relationship

I hereby authorize the childcare operation to allow my child to leave the childcare operation ONLY with the following person. Please list name and telephone number for each. Children will only be released to a parent or person designated by the parent/guardian after verification of ID.

TRANSPORTATION(Check One) I hereby give consent for my child to be transported and supervised by the operation's employees do not give consent for my child to be tranported and supervissed by the operation's employees EMERGENCY CARE(Select All That Apply) on field trips to and from home to and from school	FIELD TRIPS(Check One) I hereby give my consent for my child to participate in fieldtrips do not give my consent for my child to participate in fieldtrips Parent's Comments:	WATER ACTIVITIES I hereby give my consent for my child to participate in water activities do not give consent for my child to participate in water activities Select All that Apply sprinkler play splashing/wading pools swimming pools water table play	RECEIPT OF WRITTEN OPERATIONAL POLICIES I acknowledge receipt of the facility's operational policies including those for discipline and guidance
AUTHORIZATION FOR EMERGENCY MEDICAL ATTENTION
In the event that I cannot be reached to make arrangements for emergency medical care, I authorize the person in charge to take my child to:
Name of Physician:	Address	Phone #

Name of Emergency Medical Center:	Address	Phone #

I give consent for the facility to secure any and all necesssary emergency care for my child		Parent Signature________________________________________
List any special problems that your child may have, such as allergies, existing illnessess, previous serious illnesses, injuries and hospitalizations within the last 12 months, any medications perscribed for long-term continuous use, and any other conditions which caregiver's need to be aware of


SCHOOL AGE CHILDREN
My child attends the following school:
Name of School	Address	Phone Number

Check all that Apply	His/her immunization record is on file at the school and all required immunizations and/or tuberculosis tests are current. Hearing and vision screening records are also on file. My child has permission to ride a bus walk to/from school be released to the care of his/her sibling(s) under 18 years of age.	Name of Sibling(s)
____________________________________	Signature of Parent/Legal Guardian	__________________ Date

130 W. Holland St. | San Marcos, TX 78666 | (51 353 - 5437 | Email the Director