Register New Child - Little Sprouts Children Center

Child's First Name

Child's Last Name

Nickname (If any)

Child's Primary Language

English
Spanish
Other

Child's Date of Birth

Child's Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Does your child have siblings?

How many?

Does your child nap?

How long?

Toilet Training Info

Is your child toilet trained?

Yes
No
Somewhat

Does your child wear diapers?

Daytime
Nighttime
Both

Does your child wear Pull Ups?

Daytime
Nighttime
Both

Does your child have any toileting difficulties we should be aware of?

More About Your Child

Has your child ever been part of a childcare or group setting?

Yes
No
Further Explanation

Please tell us about that experience.

What types of activities does your child enjoy?

What are your goals for your child's time at LSCC?

Has your child experienced any out of the ordinary stressors or life changes?

Parents' Marital Status

About Guardian 1

Name: Guardian 1

Address: Guardian 1

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Phone: Guardian 1

Email: Guardian 1 *

This will be our primary email contact.

Employer: Guardian 1

Employer's Phone: Guardian 1

About Guardian 2

Name: Guardian 2

Address: Guardian 2

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Phone: Guardian 2

Email: Guardian 2

Employer: Guardian 2

Employer's Phone: Guardian 2

Emergency Contacts

Emergy Contact 1

Phone: Contact 1

Emergy Contact 2

Phone: Contact 2

Medical Providers

Child's Health Care Provider

Childs Health Care Provider Phone

Preferred Hospital Name

Preferred Hospital Phone

Child's Dental Care Provider

Child's Dental Care Phone

Medical Information

I give consent to Little Sprouts Children’s Center to use my child’s name, photo image, video or audio recordings, and artwork to be used for educational, and non-profit marketing and promotions including use in newspaper articles, newsletters, videos, website, etc. I give consent to apply SPF 50 Sunscreen to exposed parts of my child’s skin for outdoor play during peak sunshine hours. I give consent to apply Insect Repellant to exposed parts of my child’s skin for outdoor play during times when insect contact is likely. I give consent to take my child on occasional field trips. I understand that an abundance of caution will be used and all safety precautions will be taken. In the event of an accident, I release Little Sprouts Children's Center from any liability while on said fieldtrip.

Yes, I give my parental consent to the above.
No, I do not give parental consent to the above.

I authorize Little Sprouts Staff to seek any and all emergency medical and/or dental services, in my absence, with no liability to pay for said services.

Yes, I authorize
No, I do not authorize

Does your child have any allergies or sensitivities?

Please Explain

Has your child ever experienced the following? Check all that apply.

Strep/Scarlet Fever
Asthma/Wheezing
Chicken Pox
Heart Conditions
Seizures
Bloody Nose
Urination Problems
Mumps/Measles
Gastrointestinal Problems
Headaches
Ear Problems

If you checked any of the above boxes, please elaborate.

Who will be the normal pick up persons for your child?

Who will be allowed to pick up your child with a prior notice to the center?

I understand that any person who attempts to pick up the child that a staff member is not familiar with; will be required to show ID

I Understand

Upload your child’s immunization certificate

Drop your files here or click here to upload

Upload your child’s proof of physical

Drop your files here or click here to upload

Upload your child’s contract

Drop your files here or click here to upload

Upload your child’s CACFP Enrollment Form

Drop your files here or click here to upload