Parent’s Day Out

Enrollment Form

This online form follows the fields in the supplied Stone Haven Foundations Enrollment Form.

Before you begin: The policy document states that Medical, Transportation, Emergency, and Payment Agreement forms must be completed and signed before admission. Fee amounts were blank in the supplied policy document, so no fee is quoted here.

Child Information

Child Full Name

Gender

Nickname

Birthday

Age

Mother / Guardian

Mother / Guardian Name

Address

City

Zip Code

Cell #

Work #

Home / Alt #

Employer

Father / Guardian

Father / Guardian Name

Address

City

Zip Code

Cell #

Work #

Home / Alt #

Employer

Custody & Physician

Primary Custody

Physician’s Name

Phone #

Physician’s Address

Allergies & Nutrition

Does your child have allergies?

Please list allergies

Symptoms

In case of exposure, what is your desired response?

Dietary restrictions

Emergency Information

List authorized people who may act for the parent in an emergency if the parent cannot be reached.

Name

Relationship

Phone #

Second name (optional)

Relationship

Phone #

Authorized Pick-Up

For safety, a child will not be released to anyone not on this list unless prior arrangement is made by the parent. The supplied form states that listed people must show identification.

Person 1

Name

Relationship

Cell #

DL #

Person 2 (optional)

Name

Relationship

Cell #

DL #

Person 3 (optional)

Name

Relationship

Cell #

DL #

Getting to Know Your Child

Favorite color

Favorite toy

Favorite activity

Favorite food

Please tell us about your child’s personality to help us get to know and care for them.

Program Schedule

Attendance Schedule

Required Acknowledgments

I understand a transportation policy must be signed as required by the program. *

I understand required medical forms must be completed before admission. *

I understand the Payment Agreement must be completed before admission. *

I grant permission for photo/video use.

I acknowledge the program’s family privacy statement. *

I certify that the information provided is complete and accurate. *

Fields marked with * are required.

Wix form connection required. This static upload preserves the complete enrollment form and validation, but it does not store or transmit child/family information until the form is connected to Wix Forms after the Headless site is created. Do not enter sensitive information until that connection is completed.