Classroom Welcome for Infants

CLASSROOM WELCOME FOR INFANTS

Classroom Name:    Lead Teacher:    Start Date:

STUDENT INFORMATION

Date of Birth:    Student ID (if assigned):    Preferred Name:

PARENT / GUARDIAN INFORMATION

Relationship:    Primary Phone:    Alternate Phone:

EMERGENCY CONTACTS (OTHER THAN PARENT/GUARDIAN)

Relationship:    Phone:

Relationship:    Phone:

AUTHORIZED PICK-UP

Check each person authorized to pick up the child and provide contact information.

HEALTH, MEDICATION & IMMUNIZATIONS

Physician Phone:    Preferred Hospital:

Immunizations complete and current as required by program policy: Yes    No / Pending documentation to follow

FEEDING, SLEEP & DIAPERING ROUTINES

Feeding Method:    Formula/Brand (if applicable):

Breastmilk Storage and Handling Permission: I authorize the center to store and use labeled expressed breastmilk according to center procedures.

Diapering / Skin Care: The center will diaper and apply non-medicated products as needed. For application of medicated creams or ointments, provide name and instructions below and sign the medication authorization.

POLICIES, CONSENTS & AUTHORIZATIONS

Emergency Medical Treatment Authorization: In the event of a medical emergency, and if the parent/guardian cannot be reached, I authorize program staff to obtain emergency medical treatment for my child and to transport my child to the nearest appropriate medical facility. I understand I am financially responsible for all costs incurred.

Photo/Video Release: I consent to my child's photo/video being used for classroom displays, educational records, and internal communications with families.    I do NOT consent to any photos/videos of my child being used outside of emergency or required documentation.

Medication Administration: I authorize trained staff to administer medication to my child in accordance with written instructions and medication authorization forms. Prescription medication must be in the original container and accompanied by administration instructions. Over-the-counter medication requires written authorization and labeled container.

Illness Exclusion: I understand that children with fever, vomiting, uncontrolled diarrhea, or other communicable conditions as defined by the center's health policy will be excluded until cleared to return by the center or a healthcare provider. I agree to pick up my child promptly if notified of illness.

Safe Sleep Policy Acknowledgment: For infants under 12 months, the center follows a back-to-sleep policy unless a written physician authorization specifies an alternate sleep position. I confirm whether a physician authorization is provided below.

Parent/Guardian Certification: By signing below I certify that the information provided is true and correct to the best of my knowledge; I have disclosed all known allergies, medical conditions, and required health information. I acknowledge that failure to provide accurate health information may affect the center's ability to care for my child.

ENROLLMENT & FINANCIAL INFORMATION

Program Enrolling In:    Start Date:

ADDITIONAL NOTES

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