Enrollment Form Step 1 of 2 50% CompanyThis field is for validation purposes and should be left unchanged.Parent's InformationParent's Name(Required) First Last Parent's Email(Required) Enter Email Confirm Email Cell Phone(Required)Home Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Child's InformationChild's Name(Required) First Last Child's Birthdate(Required) Enrollment Date(Required) Child's Doctor(Required)Please include address and phone number.Child's Dentist(Required)Please include address and phone number.Insurance Provider Information(Required)My child has the following health conditions: Asthma Diabetes Epilepsy Developmental Delays (please explain below) Special Needs (please explain below) Heart conditions Allergies (e.g., food, environmental, insect stings, medications) Eczema or other skin conditions Chronic illnesses (e.g., juvenile arthritis, cystic fibrosis) Food allergies (e.g., peanuts, dairy, gluten) Lactose intolerance Religious or cultural dietary restrictions Vegetarian/vegan diets ADHD Autism Spectrum Disorder Sensory Processing Disorder Speech or language delays Anxiety or other mental health concerns Daily medications (name, dose, timing) Emergency medications (e.g., EpiPen, inhaler) Any medication the staff may need to administer Use of mobility aids (wheelchair, walker, braces) Physical therapy needs Fine motor skill difficulties Hearing loss or use of hearing aids Vision impairment or corrective lenses Use of assistive technology Does your child have or have had any of the following childhood illnesses?Chicken Pox(Required) Yes No Never Measles(Required) Yes No Never Rubella(Required) Yes No Never German Measles(Required) Yes No Never Mumps(Required) Yes No Never Rheumatic Fever(Required) Yes No Never Scarlet Fever(Required) Yes No Never Whooping Cough(Required) Yes No Never Has your child ever been tested for any of the above?(Required)YesNoIf yes, please describe.(Required)Has your child ever had any surgeries?(Required)YesNoIf yes, please describe.(Required)Does your child need special attention of one on one help with activities, lessons, or anything physical?(Required)YesNoIf yes, please describe.(Required)Additional CommentsInclude any special medical conditions not listed, or any chronic health problems.Known Allergies(Required)If not applicable, enter "NA". Use commas to separate allergies.Any drug reactions?(Required)If not applicable, enter "NA". Use commas to separate medications.Medical Allergies(Required)If not applicable, enter "NA". Use commas to separate medications.Medications(Required)If not applicable, enter "NA". Use commas to separate medications.Date of last tetanus shot Did your child have any reaction to the tetanus shot?YesNoSickle Cell TestYesNoResultsTB Test?YesNoResultsChild's Blood Type(Required)A+A−B+B−AB+AB−O+O−Immunization Record(Required) Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB. My child is in good mental and physical health(Required) I certify that to the best of my knowledge, my child, listed above, is in good mental and physical health and able to participate in the child care program at Victory Learning Academy.I will follow Victory Learning Academy's Sick Child Policy(Required) When my child Is contagiously ill, I understand and agree that Victory Learning Academy will not accept them for care, This Includes fever, diarrhsa, vomiting, and bad cough over 12 to 24 hours. Also communicable disease. I will follow the Sick Child Policy form and contact the Academy to see what levels deem them attending or possibly staying home before I arrive with them. My signature below certifies that my child to my knowledge, are in good health and free of any other allments that would endanger him/her or other children. I understand depending on the age of my child many of the items listed will not apply. Also by signing below I agree that this is a legally binding. Providing false Information could be grounds for termination of childcare services, forfeiture of childcare retainer, or both.SignatureYour NameYour NameYour NameYour NameDate Approved Pickup(s)Approved Pickup #1(Required) First Last Approved Pickup #1(Required)PhoneApproved Pickup #2(Required) First Last Approved Pickup #2(Required)PhoneEmergency ContactsEmergency Contact #1(Required) First Last Emergency Contact #1(Required)PhoneEmergency Contact #2(Required) First Last Emergency Contact #2(Required)PhoneEmergency Contact #3(Required) First Last Emergency Contact #3(Required)PhoneEmergency Contact #4(Required) First Last Emergency Contact #4(Required)Phone
