Child Information Packet

Child Information Packet 2019

Please complete the registration form and attach a photo of your child. All fields must be filled out completely in order to process registration.

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Child's Information

Street Address, City, State, Zip

Additional Child Info

Parent/Guardian Information

Street Address, City, State, Zip
Street Address, City, State, Zip
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Emergency Contacts/Authorized Pick Up

The following people are authorized to pick up my child and also may be contacted in an emergency or illness in the event I cannot be reached.

Persons Not Authorized To Pick Up

Please note: Rock and Roll Daycare must have a copy of the legal custody order in order to deny pick up from a parent.

About Your Child

Health Insurance

First Aid and Emergency Medical Care Consent Form

Emergency Release Form

Child Emergency Medical Information

Off-Site & Transportation Permission

Authorization for Medication Administration

Physician Authorization to Administer Medication

Health Care Plan

For health care provider to complete
For health care provider to complete

Health Evaluation Form

**This form MUST be filled out by your child's physician prior to the first day of care. If you have a separate form, please scan and attach or bring in a physical copy.
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If Tuberculin Test Given

If Chest X-rayed

Include, if tested, vision and hearing
*The AAP recommends that children from 0-12 years have health appraisal visits at: 2, 4, 6, 9, 12, 15, 18 and 24 months, and age 3, 4, 5, 6, 8, 10 and 12 years.
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Health History


(ex. foods, pets, etc.)

Last test date

Developmental History & Background Information

Please provide information for Infants and Toddlers (marked *) as appropriate to the age of your child.

Developmental History


(i.e. asthma, hay fever, insect bites, medicine, food reactions)

Eating Habits

Please inform us when your child transitions.

Toilet Habits

Sleeping Habits

Social Relationships

Daily Schedule

Tooth Brushing

Media Authorization

Research Study Authorization

Additionally, I understand that Rock and Roll Daycare may elect to provide internships for early childhood candidates and Montessori certificate candidates. These interns will be on site for a limited term, and will undergo the requirements of a satisfactory CORI and BRC prior to conducting work with children.

All Topical Products Authorization

Request for Reference

We hope that you find Rock and Roll Daycare to be a delightful place for your child and that you are pleased with the services we provide. We would greatly appreciate it if we may offer you as a reference to share with prospective clients. Please indicate below whether you would be willing to be contacted via telephone, or if you are willing to provide a letter of reference.

Rock and Roll Daycare Contract



New Family: At this time, your first month of tuition and a non-refundable deposit of two weeks tuition is due. The deposit will be applied towards the last two weeks of childcare, and seven days grace period will be given to complete registration/medical forms. Current Family: At this time, your $75.00 Re-Registering fee will process in conjunction with the following tuition payment.
Payment Schedule. All payments should be received by automatic electronic ACH. Payments will be automatically processed on the 23rd business day of each month (ex. October 23rd for November Tuition). If payment is not received at this time, your child’s enrollment may be suspended and you will be financially responsible to provide full payment for the current month prior to returning in good standing.


By signing below the parent(s)/guardian(s) are agreeing to abide by the policies set forth in the Policy Handbook. The provider may amend the Policy Handbook by giving a new copy of the changed Policy Handbook two (2) weeks prior to the effective date. I understand my child’s Child Information Packet and all necessary documents will be required, per EEC State Regulation, to be updated each year.
Parent/Guardian Signature
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