HomeProtected: Parent PortalForms: Enrollment Forms: Enrollment Company Child's Name * Age at Admission * Date of Birth * Date of Admission * Child's Home Address * Home Phone Number Primary Language Eye Color Skin Color Height Identifying Marks Hair Color Sex MaleFemale Weight Parent/Guardian Information Parent/Guardian Name * Relationship to Child Home Address Reachable Phone Number * Email Address * Business Name Business Address Business Phone Number Hours at Work Parent/Guardian Name Relationship to Child Home Address Reachable Phone Number Email Address Business Name Business Address Business Phone Number Hours at Work Additional Information Child's Physician's Name * Physician's Address Phone Number * Allergies or Special Diet? Individual Health Plan for child with a chronic health condition? * YesNo Copies of any custody agreements, court orders, and restraining orders pertaining to the child? * YesNo Special limitations or concerns? Signature By entering my name above, I confirm that all the information entered is accurate and correct as of this date. This permisson will be considered valid for one year.
