Bright Beginnings Learning Centers
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Emergency Contact/parental consent form
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Indicates required field
Child's Name
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First
Last
DATE OF BIRTH (dd/mm/year)
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GRADE ENTERING IN SEPTEMBER 2017
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HEALTH INSURANCE COMPANY NAME
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HEALTH INSURANCE POLICY / ID
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NAME OF CHILD'S PHYSICIAN/MEDICAL PROVIDER
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Phone Number
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ADDITIONAL INFORMATION ON SPECIAL NEEDS OF CHILD INCLUDING: ALLERGIES. MEDICATIONS,ETC.
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#2 Child's Name
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First
Last
[object Object]
#2 CHILD'S-DATE OF BIRTH (dd/mm/year)
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#2 CHILD'S-GRADE ENTERING IN SEPTEMBER 2017
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#2 CHILD-HEALTH INSURANCE COMPANY NAME
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ENTER "SAME" AS ABOVE IF ALL CHILDREN ARE INCLUDED IN POLICY.
#2 CHILD- HEALTH INSURANCE POLICY / ID
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# 2 NAME OF CHILD'S PHYSICIAN/MEDICAL PROVIDER
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PHONE NUMBER
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#2 CHILD'S-ADDITIONAL INFORMATION ON SPECIAL NEEDS OF CHILD INCLUDING: ALLERGIES, MEDICATION, ETC.
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#3 Child's Name
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First
Last
#3 CHILD'S-DATE OF BIRTH (dd/mm/year)
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#3 CHILD-GRADE ENTERING IN SEPTEMBER 2017
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#3 CHILD'S-HEALTH INSURANCE COMPANY NAME
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#3 CHILD'S -HEALTH INSURANCE POLICY / ID
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# 3 NAME OF CHILD'S PHYSICIAN/MEDICAL PROVIDER
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PHONE
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#3 CHILD'S-ADDITIONAL INFORMATION ON SPECIAL NEEDS OF CHILD INCLUDING: ALLERGIES, MEDICATION, ETC.
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#4 Child's Name
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First
Last
[object Object]
#4 CHILD-DATE OF BIRTH (dd/mm/year)
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#4 CHILD-GRADE ENTERING IN SEPTEMBER 2017
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#4 CHILD'S-HEALTH INSURANCE COMPANY NAME
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#4 CHILD-HEALTH INSURANCE POLICY / ID
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#4 NAME OF CHILD'S PHYSICIAN/MEDICAL PROVIDER
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PHONE
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#4 CHILD-ADDITIONAL INFORMATION ON SPECIAL NEEDS OF CHILD INCLUDING: ALLERGIES, MEDICATION, ETC.
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Address of CHILD/CHILDREN
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Line 1
Line 2
City
State
Zip Code
Country
PARENT / LEGAL GUARDIAN INFORMATION:
PARENT / GUARDIAN
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First
Last
[object Object]
PARENT / GUARDIAN EMAIL
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PARENT / GUARDIAN
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First
Last
[object Object]
PARENT / GUARDIAN EMAIL
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CELL PHONE
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CELL PHONE
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HOME ADDRESS
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Line 1
Line 2
City
State
Zip Code
Country
HOME ADDRESS
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Line 1
Line 2
City
State
Zip Code
Country
EMPLOYER'S NAME
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EMPLOYER'S NAME
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WORK PHONE
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WORK PHONE
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EMPLOYER'S ADDRESS
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Line 1
Line 2
City
State
Zip Code
Country
EMPLOYER'S ADDRESS
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Line 1
Line 2
City
State
Zip Code
Country
EMERGENCY CONTACT
Parents and Guardians are the first Emergency Contacts.
PERSON TO BE CONTACTED IN AN EMERGENCY IF PARENTS / LEGAL GUARDIANS ARE NOT AVAILABLE.
EMERGENCY CONTACT 1
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First
Last
[object Object]
PHONE
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RELATIONSHIP TO CHILD
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EMERGENCY CONTACT 2
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First
Last
[object Object]
PHONE
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RELATIONSHIP TO CHILD
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EMERGENCY CONTACT 3
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First
Last
PHONE
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RELATIONSHIP TO CHILD
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PERSON(S) TO WHOM CHILD MAY BE RELEASED
Parents must provide a full address for authorized individuals to pick-up children. We will not release children unless the full address of authorized person is listed here.
Name #1
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First
Last
PERSONS MUST PRESENT PHOTO ID BEFORE CHILD(REN) WILL BE RELEASED.
NAME #2
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First
Last
Phone Number
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Phone Number
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Address
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Line 1
Line 2
City
State
Zip Code
Country
PERSON COMPLETING THIS FORM
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First
Last
SELECT DATES OF ATTENDANCE
JUN 9
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Friday
JUN 12-JUN 16
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Monday
Tuesday
Wednesday
Thursday
Friday
JUN 19- JUN 23
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Monday
Tuesday
Wednesday
Thursday
Friday
JUN 26- JUN 30
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Monday
Tuesday
Wednesday
Thursday
Friday
JUL 5- JUL 7
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Wednesday
Thursday
Friday
JUL 10- JUL 14
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Monday
Tuesday
Wednesday
Thursday
Friday
JUL 17- JUL 21
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Monday
Tuesday
Wednesday
Thursday
Friday
JUL 24- JUL 28
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Monday
Tuesday
Wednesday
Thursday
Friday
JUL 31- AUG 4
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Monday
Tuesday
Wednesday
Thursday
Friday
AUG 7- AUG 11
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Monday
Tuesday
Wednesday
Thursday
Friday
AUG 14- AUG 18
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Monday
Tuesday
Wednesday
Thursday
Friday
AUG 21- AUG 25
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Monday
Tuesday
Wednesday
Thursday
Friday
ELECTRONIC FUNDS TRANSFER AUTHORIZATION
For Bank Account Authorization, complete and return to center management. I (we) authorize Bright Beginnings Education Center, Inc., (called “CENTER” in this Authorization) to initiate debit entries to my (our) Checking or Savings Account indicated below at the depository financial institution indicated below (called “DEPOSITORY” in this Authorization). I (we) authorize CENTER to withdraw sufficient funds to pay my (our) regular childcare tuition and/or other childcare related fees that are due and payable. I (we) acknowledge that the origination of Automated Clearing House (ACH) transactions to my (our) account must comply with the provisions of United States Law. Credit Union Members: Please contact your Credit Union to verify account and routing numbers for automatic payments. Withdraw of funds will occur the Friday before scheduled week to attend.
Your Name
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First
Last
[object Object]
Phone Number
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Depository-Bank or Credit Union Name
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Bank or Credit Union Address
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Line 1
Line 2
City
State
Zip Code
Country
Type of Account
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Checking
Saving
Routing Transit Number
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Account Number
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This authorization will remain in full force and effect until I (we) notify the CENTER in writing of its termination in such time and in such manner as to afford Bright Beginnings Education Center, Inc. and DEPOSITORY a reasonable opportunity to act upon it. Notices must be received at a minimum of 5 business days in advance of the termination date.
SUMMER CAMP REGISTRATION AND TUITION FEES
$200.00 per week for camp hours.
Extended care is available. Field trip charges will be billed separately. Breakfast, Lunch, and Snacks are included in this fee.
A non-refundable $40.00 registration fee
($20.00 per additional siblings) is due when submitting registration forms to secure your child’s placement.
Do you want to pay Registration Fee using account listed above?
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Yes
No
What is the amount you would like to pay?
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Do you want to use the account above to pay weekly tuition?
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Yes
No
What is the Weekly Tuition you will be paying?
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SUBMIT