Enrollment Form

Desired Entrance Date:

Withdrawal Date:

Child’s Information:

Last Name:

First Name:

Sex:

Age:

Date of Birth:

Social Security Number:

Home Address (Street):

City:

State:

Zip:

Home Phone Number:

Mother/Guardian 1

Name:

Phone Number:

Email:

Place of Employment:

Work Phone:

Employer’s Street Address:

City:

State:

Zip:

Home Address (If different from child’s) Street:

City:

State:

Zip:

Father/Guardian 2

Name:

Phone Number:

Email:

Place of Employment:

Work Phone:

Employer’s Street Address:

City:

State:

Zip:

Home Address (If different from child’s) Street:

City:

State:

Zip:

Child’s Living Arrangements:

Child’s Legal Guardian(s):

The child may be released to the person(s) signing this agreement or to the

Name:

Address (Street):

City:

State:

Zip:

Phone Number:

Relationship to Child:

Relationship to Parent(s) or Guardian(s):

Other Identifying Information (if any or write none):

Persons to contact in the case of emergency when parent or guardian cannot be
reached:

Name:

Telephone Number

School Information:

Does your child attend school?

School’s Name

Medical Information:

Child Doctor

Phone Number

Does your child have special needs?

Describe if yes

Does your child require any special accommodation?

Describe if yes

Does your child have any medication?

Describe if yes

AUTHORIZATION TO DISPENSE EXTERNAL PREPARATION

Do you give permission?

Do you give permission to use?
Baby Wipes, Band Aids, Neosporin, or similar ointment, Bactine, or similar first
aid spray, Sunscreen, Insect Repellent, Non-prescription ointment (i.e. A&D,
Destin, Vaseline), Baby Powder.

PARENT RELEASE FORM FOR MEDIA RECORDING

Do you give to Discovery Zone Kids to unrestricted use of the image of
my child. Such use includes the display, distribution, publication, transmission,
or otherwise use of photographs, images, and/or video taken of my child for use
in materials that include, but may not be limited to, printed materials such as
brochures and newsletters, videos, and digital images such as those on the
Discovery Zone Kids website and on Brightwheel App. I understand that a child’s
last name will never be used in conjunction with any video or digital images. If not marked differently, it will be assumed as a yes.

Grant unrestricted permission:

PARENTAL AGREEMENT WITH DISCOVERY ZONE KIDS (Medicine)

Before any medication is dispensed (prescription or non-prescription) to my
child, I will provide a written authorization, which includes date, name of child,
name of medication, prescription number (if any), dosage, date and time of day
medication is to be given. The medicine will be in the original container with
my child’s name marked on it. A blank authorization form is provided to you on
the Brightwheel App.

EMERGENCY MEDICAL AUTHORIZATION

If my child suffers an injury or illness while in the care of Discovery Zone Kids
and the facility is unable to contact me (us) immediately, it shall be authorized
to secure such medical attention and care for the child as may be necessary. I
(we) shall assume responsibility for payment for services. I authorize the
childcare facility to obtain emergency medical care for my child when I am not
available.

PARENTAL AGREEMENT WITH DISCOVERY ZONE KIDS (Meals)

Discovery Zone Kids agrees to provide childcare for my child Monday through
Friday between 6am to 6pm everyday of the week when my child is present for
care beginning from the first day of the attendance to the day of withdrawal.
My child will participate in meals provided throughout the day to include
breakfast, lunch and snacks.

My child will not be allowed to bring food from home unless there is a known
food allergy that requires special meal preps, and my child cannot be
accommodated with minor changes. A doctor’s note is required for the special
accommodation and to allow my child to bring food from home.

PARENTAL AGREEMENT WITH DISCOVERY ZONE KIDS (Sign in and Out)

My child will not be allowed to enter or leave the facility without being escorted
by the parent(s), person authorized by parent(s), or facility personnel. You are
required to use the Brightwheel App for this process, so please download ASAP,
choose our school and follow the instructions provided. You will use the PIN
provided through the Brightwheel App to sign in and out at the front desk. In
instances when you (parent/guardian) forget to sign your child in or out, you
are authorizing us (any employee of DZK) to sign your child in and out for the
attendance/meal count/CAPS billing purpose.

I acknowledge it is my responsibility to keep my child’s records current to
reflect any significant changes as they occur (i.e. – telephone number, work
location, emergency contacts, child’s physician, child’s health status, infant
feeding plans, immunization records, etc.).

The facility agrees to keep me informed of any incidents, including illness,
injuries, adverse reactions to medications, etc., which includes my child. I will
be primarily contacted through the Brightwheel App.

TRANSPORTATION AGREEMENT

The facility director agrees to obtain written authorization from me before my
child participates in routine transportation, field trips, special activities away
from facility, and water-related activities occurring in water that is more than
two (2) feet deep. A routine blank transportation form is provided to me
through the Brightwheel App. Other permission forms will be provided closer to
the planned activities that require transportation. Transportation will be available
based on the number of children attending from certain schools and is not guaranteed.

ITEMS BROUGHT FROM HOME

I will provide a small blanket (except for infants and school age children), a
change of clothes, diapers/pull-ups and wipes (if the child uses them). I will
label all items brought from home to keep them from potentially getting
misplaced or lost. If my infant takes bottles, I will prepare them at home and
label them with the name and date before leaving them and the child at the
center.

ADDITIONAL INFORMATION

Use this space to provide additional information about your additional contacts,
emergency pick-up person, media release information, medical information etc.
that we left out or did not provide you with enough space on the form. You are
welcome to provide us with any other information in this space to help us serve
you and your child better while at our center.

DZK POLICIES AND PROCEDURES

I have received a copy and agree to abide by the policy and procedures of
Discovery Zone Kids. I understand that the facility will advise me of my child’s
progress and issues relating to my child’s care as well as any individual
practices concerning my child’s needs. I also understand that my participation
is encouraged in facility activities.

I, the undersigned, have read all the information provided on this registration
document carefully and do hereby grant
permission to Discovery Zone Kids to care for my child following all the terms
and procedures described here and in detailed policy and procedures shared with
me through the Brightwheel App.

Parent/ Guardian Signature:

Date:

Facility Administrator Signature:

Date:

VEHICLE EMERGENCY MEDICAL INFORMATION

This is a required form even if your child doesn’t take part in routine
transportation. In case of emergency, a copy of this form will be sent with the
child during transportation. Please also enter this information in the
Brightwheel App for easy access in case of emergency.

Child’s Name:

Date of Birth:

Address:

Father’s Name:

Home Phone:

Work Phone:

Mother’s Name:

Home Phone:

Work Phone:

Emergency Contact(s) if parents cannot be reached:

Name:

Phone:

Name:

Phone:

Child’s Doctor: CC Health Dept (706-868-3330).

If other Doctor, Name:

Phone Number:

Medical Insurance Company

Policy Number

Medical facility the center uses: Doctor’s Hospital

Address: 3651-Wheeler Rd. Augusta, GA 30909

Child’s Allergies: My child has NO KNOWN ALLERGIES. You are accepting this statement if
not marked differently.

IF not present, mark no and write none in the description.

If present, mark yes and describe.

Describe

Prescribed Medications: My child takes NO PRESCRIBED MEDICATIONS. You are accepting
this statement if not marked differently.

If not taken, mark no and write none in the description.

If taken, mark yes and describe.

Describe

Special needs/conditions: My child has NO SPECIAL NEEDS/CONDITIONS. You are accepting
this statement if not marked differently.

If not present, mark no and write none in the description

If present, mark yes and describe.

Describe

Authorization to Secure Medical Care: In the event of an emergency involving my child,
and if Discovery Zone Kids cannot get in touch with me, I hereby authorize any needed
emergency medical care. I further agree to be fully responsible for all medical expenses
incurred during the treatment of my child.

Parent’s Name:

Parent’s Signature:

Witness By:

Date:

Infant Feeding Plan (To fill out if enrolling an infant)

Provide prepared Formula/Breast Milk/Baby Food with your child’s last name,
first name and date on each container. Unused food will be discarded after one
use if fed straight from a container. Formula/Breast Milk will be discarded after
it is served one time and left outside for an hour. Unused bottles will be sent
home each day.

Child’s Name:

Birthdate

Respond yes or no to all items below.

Does this child take a bottle?

Is it warmed?

Does the child hold his/her own bottle?

Can the child feed self?

Does your child eat the following?

Strained foods

Whole Milk

Baby foods

Table foods

Breast Milk

Another item

Formula

Type of formula used if any:

Amount of formula/breastmilk/milk given at the time of enrollment:

Amount

Date

Does your child take a pacifier?

If yes, when does your child take a pacifier. If not, write Not Applicable. Please
know that a pacifier cannot have a toy attached to it. If provided with a clip or toy, it will be removed.

Does your child have any allergies (including any premixed formula)?

If yes, what is the child allergic too? If not, write None.

Provide details

In this space provide in as much details as possible:

A list of food your child likes.

A list of food your child dislikes

Any known allergies to food.

Your child’s current feeding schedule: Create a schedule based on how often (with how many
hours of gap) and how many ounces of formula/food is to be given to the child while at the center if you
do not already have a schedule. Make sure to let teachers know each day when your child was fed before
leaving your child at the center, so they can follow your schedule accurately.

FORMULA SCHEDULE if applies

Time

Amount

Type

FOOD SCHEDULE if applies

Time

Amount

Type

INTRODUCTION OF SOLID FOODS The introduction of age-appropriate solid foods should
preferably occur at six months of age, but no sooner than four months. Has the parent
discussed with the child’s primary caregiver that the child has met appropriate
developmental skills for the introduction of solid foods?

Parent Initials:

The child has reached the following developmental skills:

Can hold his/her head steady?

Opens mouth/leans forward in anticipation of food offered?

Closes lips around a spoon?

Transfers food from front of the tongue to the back and swallows?

Instructions for the introduction of solid foods: Write None Currently if not
ready yet for solids.

DO NOT SERVE THESE FOODS TO MY CHILD: (Give reason, provide a doctor’s note
if allergic/intolerant to certain foods and provide a signed request (parent’s
signature) if certain foods are not to be given because of religious reasons.
List of foods and Reason (Attach signed document)

Updated amount of formula/breastmilk/milk: This is to be filled out each time the amount
changes or you could choose to fill out an entirely new form.

Amount:

Date updated:

Amount:

Date updated:

Parent/Guardian Signature

Date

Safe Sleep Practices/Policies (To be signed if enrolling an infant)

Child’s Name

Date

Parent/Guardian Name

Safe Sleep Practices/Policies:

Infants will be placed on their backs in a crib to sleep unless a writtenphysician’s statement authorizing another sleep position is provided. Thewritten statement must include how the infant shall be placed to sleepand in a time frame that the instructions are to be followed.
Cribs shall follow CPCS and ASTM safety standards. They will bemaintained in good repair and free from hazards.
No objects will be placed in or on the crib with the infant. This includes,but is not limited to covers, blankets, toys, pillows, quilts, comforters,bumper pads, sheepskins, stuffed toys, or other soft items.
No objects will be attached to a crib with a sleeping infant, such as, butnot limited to, crib gyms, toys, mirrors, and mobiles.
Only sleepers, sleep sacks and wearable blankets must be provided by theparent/guardian and that fit according to the commercial manufacture’sguidelines and will not slip up around the infant’s face may be worn forthe comfort of a sleeping infant.
Individual crib bedding will be changed daily, or more often as needed.Bedding for cots/mats will be laundered daily or marked for individual use.If marked for individual use, the sheets/covers must be laundered weeklyor more frequently if needed. Discovery Zone Kids will provide individualcots and cribs for children. The sheets will be changed daily or more oftenif needed. Individual blankets for older children will be washed weekly.They will be sent home if brought from home.
Infants who arrive at the center asleep or fall asleep in other equipment,on the floor or elsewhere, will be moved to a safety-approved crib forsleep.
Swaddling is not permitted unless a written physician’s statementauthorizing it for the infant is provided. The written statement mustinclude how the infant shall be placed to sleep and in a time frame thatthe instructions are to be followed.
Wedges or other infant positioning devices and monitors will not bepermitted unless a written physician’s statement authorizing it for theinfant is provided. The written statement must include instructions onhow to use the device and a time frame for using it.

I acknowledge that the director or designee has advised me of the safe sleep
practices followed by the facility.

Signature

Date

Transportation Agreement (To be filled out for school age children)

This is to certify that I give Discovery Zone Kids permission to transport my child. My
child will be transported Monday through Friday from Discovery Zone Kids to my child’s
school and then will be picked up from my child’s school and brought back to Discovery
Zone Kids for me to pick up later. Name of my child

My child attends

school. He/she will be
transported following the school pick up and drop off schedule for his/her school listed
below. Any/All my emergency contacts are authorized to receive my child from the
center in the event of my absence.

Pick Up Location	Pick Up Time	Approx. Distance	Drop Off Location	Drop Off Time
Discovery Zone Kids	8:10am	2 miles	Lewiston ES	8:25am
Lewiston Elementary	3:45pm	2 miles	Discovery Zone Kids	4:00pm

Pick Up Location	Pick Up Time	Approx. Distance	Drop Off Location	Drop Off Time
Discovery Zone Kids	8:10am	2 miles	Evans Elementary	8:20am
Evans Elementary	3:45pm	2 miles	Discovery Zone Kids	4:00pm

Pick Up Location	Pick Up Time	Approx. Distance	Drop Off Location	Drop Off Time
Discovery Zone Kids	8:10am	6 miles	Baker Place ES	8:30am
Baker Place ES	3:45pm	6 miles	Discovery Zone Kids	4:00pm

Pick Up Location	Pick Up Time	Approx. Distance	Drop Off Location	Drop Off Time
Discovery Zone Kids	8:10am	6 miles	Westmont ES	8:30am
Westmont ES	3:45pm	6 miles	Discovery Zone Kids	4:00pm

In the event the authorized person is not present to receive my child before the center
closes, the following procedures will be followed: A message will be sent through the
Brightwheel App first for all authorized users to see and respond. If no replies are
received within five minutes, all the available numbers provided by the parents on file
will be called. Please specify if other procedures are to be followed. Write none if no
changes are needed.

In the event my child is not to be transported as outlined above, I agree to notify
Discovery Zone Kids at (706) 496-2489.

Parent/Guardian

Date

Transportation will be available based on the number of children attending from certain schools and is not guaranteed.
Please confirm during registration.

Enrollment Form

VEHICLE EMERGENCY MEDICAL INFORMATION

Infant Feeding Plan (To fill out if enrolling an infant)

Safe Sleep Practices/Policies (To be signed if enrolling an infant)

Transportation Agreement (To be filled out for school age children)

GENERAL RELEASE

PHOTOGRAPH/VIDEOTAPE RELEASE

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Admission Form

Enrollment Form

VEHICLE EMERGENCY MEDICAL INFORMATION

Infant Feeding Plan (To fill out if enrolling an infant)

Safe Sleep Practices/Policies (To be signed if enrolling an infant)

Transportation Agreement (To be filled out for school age children)

GENERAL RELEASE

PHOTOGRAPH/VIDEOTAPE RELEASE

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