Student Registration Form | Charlottesville Day School

Student Information

Child*

First Last

Birth Date*

Sex*

Male
Female

Chronic physical problems, pertinent developmental information, or special accommodations needed*

Previous day care programs and schools attended*

If child attends this center and another school/program, give name of school/program*

Parent/Guardian Information

Parent 1 Name*

First Last

Parent 1 Employer*

Parent 1 Email*

Person(s) or agency having legal custody of child*

Parent 1 Home Phone*

Parent 1 Business Phone

Parent 1 Cell Phone

Parent 1 Address*

Street Address City State ZIP Code

Parent 2 Name

First Last

Parent 2 Email

Parent 2 Home Phone

Parent 2 Business Phone

Parent 2 Cell Phone

Same address as Parent 1

Parent 2 Address

Street Address City State ZIP Code

Emergency Info

Child's Physician*

Child's Physician Phone*

Emergency Contact 1*

First Last

Please list 2 LOCAL emergency contacts that are NOT the parents or guardians of the child.

Emergency Contact 1 Address*

Street Address City State ZIP Code

Emergency Contact 1 Phone*

Emergency Contact 2*

First Last

Please list 2 LOCAL emergency contacts that are NOT the parents or guardians of the child.

Emergency Contact 2 Address*

Street Address City State ZIP Code

Emergency Contact 2 Phone*

Allergies or Intolerance to Food, Medication, etc., and Action to Take in an Emergency*

Person(s) Authorized To Pick Up Child*

Person(s) NOT Authorized To Pick Up Child*

Agreements

CDS agrees to notify the parent(s)/guardian(s) whenever the child becomes ill and the parent(s)/guardian(s) will arrange to have the child picked up as soon as possible if so requested by the center.
The parent(s)/guardian(s) authorize CDS to obtain immediate medical care if any emergency occurs when the parent(s)/guardian(s) cannot be located immediately. **
The parent(s)/guardians agree to inform CDS within 24 hours or the next business day after his child or any member of the immediate household has developed a reportable communicable disease, as defined by the State Board of Health, except for life threatening diseases which must be reported immediately.

* Appropriate paperwork such as custody papers shall be attached if a parent is not allowed to pick up the child.

* NOTE: Section 22.1-4.3 of the Code of Virginia states that unless a court order has been issued to the contrary, the noncustodial parent of a student enrolled in a public school or day care center must be included, upon the request of such noncustodial parent, as an emergency contact for events occurring during school or day care activities. 032-05-252/11 (06/05)

-CDS agrees to notify the parent(s)/guardian(s) whenever the child becomes ill and the parent(s)/guardian(s) will arrange to have the child picked up as soon as possible if so requested by the center. -The parent(s)/guardian(s) authorize CDS to obtain immediate medical care if any emergency occurs when the parent(s)/guardian(s) cannot be located immediately. ** -The parent(s)/guardians agree to inform CDS within 24 hours or the next business day after his child or any member of the immediate household has developed a reportable communicable disease, as defined by the State Board of Health, except for life threatening diseases which must be reported immediately. **If there is an objection to seeking emergency medical care, a statement should be obtained from the parent(s) or guardian(s) that states the objection and the reason for the objection.

Parental Signature*

Date

Untitled

First Choice
Second Choice
Third Choice