Child Registration Form

Parental Consent & Medical Authorization Form

In the event my child becomes ill or sustains an injury while participating in the Child Development Center of Double Oak Community Church, Birmingham, Alabama; I the undersigned, give my permission to those in charge to take whatever steps are necessary to stop bleeding and to administer first aid including emergency transport if I cannot be reached immediately. I also consent to an x-ray examination, anesthesia, medical, dental, or surgical diagnosis and treatment and hospital care, and the administration of drugs or medicine to be rendered to my child under the general or specialized supervision, and upon the advice of a duly licensed physician and/or surgeon. I agree to be responsible for any emergency medical expenses incurred. (If parent/guardian refuses to sign, instructions must be attached stating what procedure the program is to follow in an emergency.)

eSign by Typing Parent/Guardian's Name Below

First Name

Last Name

Date

MM

DD

YYYY

Mother's Name

First Name

Last Name

Mother's Phone

(###)

###

####

Father's Name

First Name

Last Name

Father's Phone

(###)

###

####

Pediatrician and Phone Number

Dentist and Phone Number

Child's Allergies

What is your child's normal reaction to their allergen?

Action taken if a reaction occurs

List any medication (over the counter or prescription) that your child takes on a routine or scheduled basis

Insurance Company

Contract #

Name of person on insurance card

If parents cannot be reached, list the persons authorized to act on their behalf in case of emergency, and their phone numbers

Family Program Agreement

Picture and Video Permission

Photographs of children may be subject to public display in CDC classrooms throughout the year. Children’s names will not be publicized with displayed photographs. On certain occasions, photography companies selected by the CDC will be allowed to make photographs that will be offered to parents for purchase. Teachers may also photograph/video class activities that will be shared only with families of children in the classroom through class parent group texts and/or Brightwheel.

YES, my child(ren) can be photographed and/or videotaped. These images may be used throughout the year for school displays, CDC program slide presentations, Brightwheel, and text messages for CDC families only.

No, my child(ren) cannot be photographed or videotaped.

eSignature of Parent/Guardian

First Name

Last Name

Date

MM

DD

YYYY

Family Financial Agreement

I understand that all program fees are to be paid by August 16, 2023. I agree to pay the yearly tuition charge of: • $2,300 or $230 per month paid in 10 monthly installments, August 2023 through May 2024 for a student who attends class MWF (three days per week). • $3,100 or $310 per month paid in 10 monthly installments, August 2023 through May 2024 for a student who attends class M-F (5 days per week). I agree to pay a $15.00 late fee if my child(ren)’s tuition is paid after the 10th day of the month. The late fee will be added to the following month’s tuition bill. I agree to pay a yearly supply fee per child in the amount of $150.00 which can be paid in full in August 2023 or divided into equal payments of $75.00 that will be paid in August 2023 and $75.00 in January 2024. I understand that no reduced rates will be given for illness, vacation, holidays, inclement weather, or early withdrawal from the program. Monthly tuition is non-refundable. There will be no makeup days. I understand that if I choose to withdraw my child(ren) for any reason, I must give the Director a written notice of two weeks and pay the full tuition for the month during which my child is withdrawn. If the CDC is forced to close for an extended period due to a nation-wide or state-wide mandate, a major health crisis, or a natural disaster of any kind, tuition will be charged for the month during which the event occurs. Tuition will not be charged for subsequent months if the program remains closed due to such an event.

eSign by Typing Your Name Below

First Name

Last Name

Date

MM

DD

YYYY

Family Authorized Pick Up Form

Please list the names of the children in your family who attend the CDC:

I hereby give my permission for the following persons to pick up the child(ren) I have listed on this form from the Double Oak Community Church Child Development Center. I understand these persons, if not known to CDC staff members, will be asked to show valid picture identification when picking up my child the first time for safety purposes.

List all persons INCLUDING PARENTS allowed to pick up a child in this family

THE CDC WILL NOT RELEASE A CHILD IN THIS FAMILY FOR PICK UP TO ANYONE WHO IS NOT LISTED ABOVE WITHOUT WRITTEN CONSENT FROM A PARENT OF THIS CHILD

eSign by Typing Your Name Below

First Name

Last Name

Date

MM

DD

YYYY