801 Vanesa Ln. Ste. E, Wylie, TX 75098

(972) 575-8881

Child’s Name		Date of Birth		Child’s Home Telephone No.

Child’s Home Address

Date of Admission	Date of Withdrawal

Parent’s or Guardian’s Name			Address (if different from child’s address)

Mother’s Work Phone	Mother’s Cell Phone		Father’s Work Phone		Father’s Cell Phone

Give the name, address and phone number of person to call in case of an emergency if parents / guardian cannot be reached:						Relationship

I hereby authorize the childcare operation to allow my child to leave the childcare operation ONLY with the following persons. Please list name & telephone number for each. Children will only be released to a parent or a person designated by the parent/guardian after verification of ID.

INITIAL ALL THAT APPLY: 1. TRANSPORTATION:	I hereby give consent for my child to be transported and supervised by the Bounce Town’s employees. ____for emergency care ___on field trips ____to and from school
2. FIELD TRIPS:	I ___ give my consent	___ do not give my consent - for my child to participate on Field Trips:
Parent’s Comments:
3. RECEIPT OF WRITTEN PARENT HANDBOOK: I acknowledge receipt of Bounce Town’s Parent Handbook including those for discipline and guidance.
4. PHOTO/VIDEO/INTERNET: I ___ give ___ do not give - Bounce Town permission to photo and/or video my child. I ___ give ___ do not give - Bounce Town permission to place photos of my child on the website (www.Bounce-Town.com).
5. HOMEWORK ASSISTANCE: I ___ give ___ do not give - Bounce Town permission to review my child’s school folder for homework assignments. I ___ give ___ do not give - Bounce Town permission to assist my child with homework assignments as needed or requested.

AUTHORIZATION FOR EMERGENCY MEDICAL ATTENTION: In the event I cannot be reached to make arrangements for emergency medical care, I authorize the person in charge to take my child to:
Name of Physician:	Address, City, State, Zip:	Ph.#:

Name of Emergency Medical Care Facility:	Address, City, State, Zip:	Ph.#:

I give consent for the facility to secure any and all necessary emergency medical care for my child.
	Signature - Parent or Legal Guardian

List any special problems that your child may have, such as allergies, existing illness, previous serious illness, injuries and hospitalizations during the past 12 months, any medication prescribed for long-term continuous use, and any other information which caregiver’s should be aware of:

____________________________________________________________ ______________

Signature – Parent or Legal Guardian Date

SCHOOL INFORMATION:

My child attends the following school:

Name of School and Address, City, State, Zip

School Ph.#

INITIAL THAT APPLY:

His / her immunization record is on file at the school and all

required immunizations and/or tuberculosis test are current.

Vision and Hearing screening records are also on file.

My child has permission to be released to the care of his/her sibling(s) under 18 years old

Name of Sibling(s):