Palmetto Child Care is doing registration at this time. Registration fee is a non-refundable fee in the amount of $80.00 at the time of registration. NO ENROLLMENT WILL BE RESERVED UNTIL A REGISTRATION FEE IS PAID IN FULL! Registration forms can be emailed to mamd2p@netzero.com, or mailed to Megan Danner at 3525 Iron Horse Dr. Suite 108 Ladson, SC 29456.
Yearly registration is held in June each year. The registration will give us an accurate number of students enrolling for the next school year. It will also allow us to manage or update any toys or equipment needed for possible growth expansion. The yearly registration amount due will be $25.00.
Infant room rates are $145.00,1-2 year old rates are $140.00, 3-5 year olds are $135.00 a week and the 4-5 year olds are $130.00 aweek.
Registration Form
Please print clearly with blue or black ink.
Child’s Full Name: _______________________________ Birth Date: _________________
Address: _________________________________ Home Phone: _( )___________________
City: ____________________________________ State: _____Zip Code: _________________
Nickname: _______________________________ Social Security #: _____________________
Mother’s Full Name: _______________________ Home Phone: ( )____________________
Address: _________________________________Social Security #: _____________________
City: ____________________________________ State: _____Zip Code: _________________
Occupation: ____________________________ Work Phone: ( )______________ext._______
Name of Employer: ______________________ Pager or Cellular Phone: ( )_______________
Business Address: _______________________ City: __________________________________
Work Hours: ___________________________ Driver’s License # _______________________
Father’s Full Name: _______________________ Home Phone: ( )____________________
Address: ________________________________ Social Security #: ____________________
City: ___________________________________ State: _____ Zip Code: ________________
Occupation: ____________________________ Work Phone: ( )______________ext.______
Name of Employer: ______________________ Pager or Cellular Phone:__________________
Business Address: _______________________ City: _________________________________
Work Hours: ___________________________ Driver’s License # _______________________
Parent/Guardian with legal custody _________________________________________________
Parents are: Married ___ Living Together___ Divorced ___ Separated ___ Widowed ___ Single ___
Other Household Members:
Names: ____________________________ Ages: _________ Relationships _________________________________________________________________________________________________________________________________________________________________________________________
Emergency Contacts
(Within 20 mile radius of daycare other than parent or guardian)
Primary Emergency Contact (other than parents or guardian) ____________________________________
Home Phone: __________________________________ Work Phone: __________________________
Relationship to Child: ___________________________________________________________________
Address:______________________________________________________________________________
Secondary Emergency Contact (other than parents or guardian) ____________________________________
Home Phone: __________________________________ Work Phone: __________________________
Relationship to Child: ___________________________________________________________________
Address:______________________________________________________________________________
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Person (s) authorized to pick up my child: (Besides parents, guardians, or emergency pick ups)
Name: __________________________________ Comment ________________________________________________________________________________________________________________________________________________________________
Kid Code: _____________________(Secret word between parent & child for identification and pick up)
Person (s) NOT authorized to pick up my child: (Besides parents, guardians, or emergency pick ups)
Name: __________________________________ Comment ______________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Name of other school child attends: _________________________ Phone: _____________________________
Emergency Release
Consent to Emergency First Aid & Transportation:
I hereby give permission that my child, _________________________, may be given emergency treatment by a staff member at Palmetto Child Care LLC. I also give permission for my child to be transported by car, ambulance, or Aid car to an emergency center for treatment, and agree to hold ________________________________________________ and its employees harmless.
Parent’s Signature _________________________________________ Date: __________________________
Consent to Medical Care and Treatment:
In the event that I cannot be contacted immediately, medical of surgical treatment can be administered to my child in the case of an accident or emergency, as prescribed by a treating physician, and hold __________________________ and its employees harmless.
Parent’s Signature _________________________________________ Date: __________________________
Emergency Information
1. Child’s Physician: ________________________________ Phone: ( )_____________________________
2. Preferred Hospital: ________________________________ Phone: ( )____________________________
3. Insurance Company: ______________________________ Policy #: _______________________________
4. Regular Medications: _____________________________________________________________________
5. Blood Type: ____________________________________________________________________________
6. Medicine allergic to: _______________________________________________________________________
7. Food Allergies: ___________________________________________________________________________
8. Any other Allergies: ______________________________________________________________________
9. Any special health conditions: _______________________________________________________________
Field Trip Permission
I hereby request that my child, ______________________________________, be permitted to participate in field trips, to the park, or any other activities that would involve taking the child outside of the daycare for his/her benefit in attendance at this facility.
Parent’s Signature: ______________________________________________ Date: ____________________
Persons signing contract are responsible for payment:
Parent/Guardian (Mother) ________________________ Parent/Guardian (Father)______________________
understand this is a legally binding contract, and I have read it and understand it.