Angel’s Korner Daycare & Learning Center

Angel’s Korner Daycare & Learning Center 517 Braxton Rd

Front Royal, Va 22630

[phone] Main Office

Child’s Name Nickname Date of Birth Sex

Address Home Phone
Chronic Physical Problems/Pertinent Developmental Information/Special Accommodations Needed
Previous Child Day Care Programs and Schools Attended If Child is School Age, Please List School and Grade

Father Place Employed Business Phone

Home Address Home Phone
Cell Phone /Other Numbers Where You May Be Reached E-Mail Address

Mother Place Employed Business Phone

Home Address Home Phone
Cell Phone/Other Numbers Where You May Be Reached E-Mail Address

Person(s) or Agency Having Legal Custody of Child

Home Address Home Phone
Business Address Business Phone

Allergies or Intolerance to Food, Medication, etc., and Action to Take in an Emergency

Child’s Physician Office Phone
Two People to Contact if Parent(s) Cannot Be Reached: *They CANNOT have the same address as either

parent

1._________________________________________________________________________________________________

Name Address Phone Number(s)

2._________________________________________________________________________________________________

Name Address Phone Number(s)

Person(s) Authorized To Pick Up Child
Person(s) NOT Authorized To Pick Up Child

• 
  Appropiate paperwork such as custody papers shall be attached if a parent is not allowed to pick up the child.
  

• 
  NOTE: Section 22.1 – 4.3 of the Code of Virginia states that unless a court order has been issued to the contrary, the noncustodial parent of a student enrolled in a public school or day care center must be included, upon the request of such noncustodial parent, as an emergency contact for events occurring during school or day care activities.
  

AGREEMENTS

1. 
   The child day care center agrees to notify the parent(s)/guardian(s) whenever the child becomes ill and the parent(s)/guardian(s) will arrange to have the child picked up as soon as possible if so requested by the center.
   

2. 
   The parent(s).guardian(s) authorize the child day care center to obtain immediate medical care if any emergency occurs when the parent(s)/guardian(s) cannot be reached immediately.**
   

3. 
   The parent(s)/guardian(s) agree to inform the center within 24 hours or the next business day after his child or any member of the immediate household has developed a reportable communicable disease, as defined by the State Board of Health, except for life threatening diseases which must be reported immediately.
   

4. 
   The parent(s)/guardian(s) have read and understand ALL policies and procedures outlined in the Angel’s Korner Handbook before signing this registration form. Yes____ No____
   

5. 
   The parent(s)/guardian(s) give permission for their child to participate in activities and field trips with Angel’s Korner. All children are transported by an Angel’s Korner vehicle with state inspection and under state guidelines regarding car seats, seat belt and etc. Yes____ No____
   

Signatures
________________________________________________ ____________

Parent(s)/Guardian(s) Signature Date

_________________________________________________ ____________

Administrator of Center Date

Date Child Entered Care___________________ Date Left Care__________________
** If there is an objection to seeking emergency medical care, a statement should be obtained from the parent(s)/guardian(s) that states the objection and the

reason for the objection.

OFFICE USE ONLY

IDENTITY VERIFICATION

Place of Birth Birth Date Birth Certificate Number Date Issued

Other Form of Proof Date Documentation Viewed Person Viewing Documentation
Date of Notification of Local Law-Enforcement Agency (when required proof of identity is not provided):__________
Proof of the child’s identity and age may include a certified copy of the child’s birth certificate, birth registration card, notification of birth (hospital, physician midwife record), passport, copy of the placement aggreement or other proof of the child’s identity from a child placing agency (foster care and adoption agency (foster care and adoption agencies), record from a public school in Virginia, certification by a principal or his designee of a public school in the U.S. that a certified copy of the child’s birth record was previously presented or copy of the entrustment agreement conferring temporary legal cutsody of a child to an independent foster parent. Viewing the child’s proof of identity is not necessary when the child attends public school in Virginia and the center assumes responsibility for the child directly from the school (i.e., after school program) or the center transfers responsibility of the child directly to school (i.e., before school program). While programs are not required to keep the proof of the child’s identity, documentation of viewing this information must be maintained for each child.


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