ELC Registration Early Learning Center Online Registration Use the form below to register your child. ChildName* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone No.*Main Email Contact for Child* Sex*MaleFemaleOtherBirthday* MM slash DD slash YYYY Parent/GuardianParent's Name First Last Email Address Cell PhoneAddress (if different from child) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code EmployerWork Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Work PhoneParent's Name First Last Email Address Cell PhoneAddress (if different from child) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code EmployerWork Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Work PhoneName of person(s) or agency having legal custody of child First Last Email Address Cell PhoneAddress (if different from child) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code EmployerWork Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Work PhoneEmergency InformationName* First Last Home Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Relationship to Child*Name* First Last Home Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Relationship to Child*Person(s) Authorized to Pick Up Child*Person(s) NOT Authorized to VISIT or Pick Up Child*AgreementsParents are requested to make payments promptly each pay period.* Weekly (Monday of each week) Monthly (in advance) Signature*Parent Statement of UnderstandingThe following information is important for the safety and protection of your child. Please read the information and add your signature below. Your signature below indicates that you have read and understand them.* Yes No - I understand that I am not to leave my child at the First Baptist Church ELC site unless a staff member is there to receive and supervise my child. - I understand that my child will not be allowed to leave the program site with an unauthorized person. Any person authorized to pick-up my child must either be listed with the ELC or other arrangements must be made by calling the ELC office to inform them of a change. - I understand that should a person arrive to pick up my child who appears to be under the influence of drugs and/or alcohol, for the child's safety, staff may have no resource but to contact the police. Please do not put staff in a position where they have to make this judgment call. - I understand that the ELC is mandated, by state law, to report any suspected cases of child abuse or neglect to the appropriate authorities for investigation. - I have received a copy of the First Baptist Church ELC Child Care Handbook/Parent Policies and Procedures. - I have read and understand the statements above and ELC Ministry Policies and Procedures. - The First Baptist Church ELC Ministry agrees to notify the parent/guardian whenever this child becomes ill, and the parent/guardian agrees to pick the child up thereafter as soon as it is feasible.The following information is important for the safety and protection of your child. Please read the information and add your signature below.* I agree that I have read and understand the policies above.- I understand that I am not to leave my child at the First Baptist Church ELC site unless a staff member is there to receive and supervise my child. - I understand that my child will not be allowed to leave the program site with an unauthorized person. Any person authorized to pick-up my child must either be listed with the ELC or other arrangements must be made by calling the ELC office to inform them of a change. - I understand that should a person arrive to pick up my child who appears to be under the influence of drugs and/or alcohol, for the child's safety, staff may have no resource but to contact the police. Please do not put staff in a position where they have to make this judgment call. - I understand that the ELC is mandated, by state law, to report any suspected cases of child abuse or neglect to the appropriate authorities for investigation. - I have received a copy of the First Baptist Church ELC Child Care Handbook/Parent Policies and Procedures. - I have read and understand the statements above and ELC Ministry Policies and Procedures. - The First Baptist Church ELC Ministry agrees to notify the parent/guardian whenever this child becomes ill, and the parent/guardian agrees to pick the child up thereafter as soon as it is feasible.In case your child should need immediate emergency medical care at a hospital before we could get your permission, do you hereby agree for this treatment to be administered by a doctor?* Yes No Parent/Guardian Signature*Parent/Guardian Signature*Responsibilities* I/We hereby agree to the terms of this contract.The parties agree that the First Baptist Church ELC shall not be responsible for medical expenses incurred by or for the child, not covered by insurance.Contract for Child Care During School TermPerson(s) Responsible for Payments*Full-Day DaycareChild's name After School, 5 DaysChild's name Enrollment/TerminationNo space for your child will be reserved until the registration fee is paid. Failure to make timely payments can result in immediate dismissal without notice. First Baptist Church ELC Ministry reserves the right to terminate enrollment upon two weeks notice without cause, and to terminate child care immediately for any act, word or condition of the child or parent causing disruption, safety concerns or health concerns for the child, other children, or employees of the First Baptist Church ELC Ministry.* I agree to this policy.Health InformationChild's Physician*Phone*Insurance Company*Policy Number*Insurance Company's Address*Please list your child's allergies, if any.Medicine, food, environmentPlease list any medications your child takes.Toilet HabitsSleep/Nap HabitsPreschoolEating Habits and DifficultiesBehavior Habits at HomeCheck any that apply: Sucks Thumb Bites Nails Temper Tantrums Fears Other Behavior HabitsHas the child attended preschool before? Yes No This field is hidden when viewing the formWhere?What is your usual manner of disciplining the child?Child's Favorite Play ActivityDoes your family attend church? Yes No This field is hidden when viewing the formWhere?Is the child involved in any special groups or activities?Dancing, music, etc.Please list any additional circumstances regarding your child's physical or emotional status of which you would like us to be aware.Are there any additional family members living at home?