RCC Registration Form
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Email *
Rhema Childcare Center
Today's Date: *
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Child Name: *
Birthdate: *
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Gender: *
Child's Address:  *
City/State/Zip Code *
Full Name of Mother: *
Email Address: *
Home Number (optional)
Work Number: *
Cell Number: *
Place of Work: *
Work Hours:  *
Emergency Contacts
Minimum 3 contacts, other than parents, to contact in case of emergency/authorized to pick up child:Contact 1st/2nd. 
1. Name: Relationship to child: Home/Cell Number:  *
2. Name: Relationship to child: Home/Cell Number:  *
3. Name: Relationship to child: Home/Cell Number:  *
Other Person(s) Authorized to pick up child:
Minimum 3 contacts
1. Name: Relationship to child: Home/Cell Number: 
2. Name: Relationship to child: Home/Cell Number:  *
3. Name: Relationship to child: Home/Cell Number: 
Child's Health Information & History
  1. Heath Plan :
  2. Group#:
  3. ID#:
Are your child's immunizations up to date? *
If not up to date , please explain: *
Does child have any known health problems? *
Does your child get colds/flu often? *
Does your child have any special needs or a family service plan? *
Please list any serious prior injuries: *
Check any of the following illnesses the child has had: *
Required
Does your child have any known allergies? *
If yes, what are they and what are your child's reactions: *
Does your child take any medication on a regular basis? *
If yes please list the name of the medication(s) and the medical condition for which it is taken: *
Does your child have any speech, hearing or visual problems?  *
Have your child ever been tested for the above? *
Please comment on any other medical information/or special need the child care provider should be aware of: *
Medication & Emergency Care Authorization
I authorize RHEMA CHILDCARE CENTER to administer the medications authorized below as deemed necessary by staff for the comfort and well-being of my child. Medications will be administered in the dosages recommended for my child's age and weight. This authorization is in effect my child is enrolled, unless revoked by me and I understand that I will be notified when I pick up my child  or prior to by phone or email if any medications were given. 
I authorize use of typical first aid supplies including but not limited to Neosporin, anti-bacterial spray, cortisone, sunburn treatments, band-aids, and liquid Band-Aids. *
I authorize use of preventative supplies, such as un block, bug repellant, hand lotion, diaper rash cream, etc. *
I authorize use of pain relievers such as acetaminophen or ibuprofen. *
I authorize use of children's cough syrup, strips or (cough drops as appropriate for age).  *
I authorize use f children's allergy or cold medicine for runny or stuffy nose. (must have medical form on file) *
I authorize use of children's stomach ache remedies, such as children's Pepto. *
NOTE: Child must have medical form on file aside from illnesses above:
If you would like  for your child to take a specific brand of medication, please provide it with doctor notice or notification. All Medications must be labeled with your child's name and kept locked. Prescription medications will require separate authorizations for each occurrence and must be sent to school in original prescription bottle/container. 
I authorize RHEMA CHILDCARE CENTER to obtain the following services for this child if necessary: Public Health Nurse, Physician, Emergency Room, EMS, and/or Ambulance transport in the event of an emergency. (Ambulance fees and/or health care cost are the responsibility of the parent /guardian). *
Photo Authorization
Photographs and videos are taken during on separated occasions such as  outdoor/indoor activities, special occasions as well as in the normal course of our day. We use these pictures /videos for teaching, sharing information about their day, arts & crafts, albums, classroom books, pictures CD's and various other things. Photos which may include my child may be given to families who also attend this program or may appear in the newspaper or on flyers unless otherwise noted by you.
I give permission to RHEMA CHILDCARE CENTER to take photographs/videos of the above named child(ren). Photos used in classroom only or give to parents as a remembrance of their child's year (including other families in the program). *
I give permission for photos/videos to be posted on Facebook or Instagram (to share your child's day).
Clear selection
I give permission for my child's photo to be used on printed marketing materials (pamphlets, flyers, etc.) *
Required
Electronic Signature of Parent/Guardian:  *
Type name as your electronic signature: 
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