Learning Club Enrollment Form

Other than you who has permission to pick up your child?

In case of an emergency, I give permission for any of the following individuals to be contacted and my child may be released to any of them.

Who does not have permission to pick up your child? If applicable (a copy of supporting court document must be on file)

Child Health Information

Special health problem? Yes or No? If Yes, specify.

Allergies, including drug reactions Yes or No? If Yes, specify.

Consent to medical care and treatment of minor children

I give permission that my child may be given first aid/emergency treatment by a child care provider/qualified staff at Milestones.

When I cannot be contacted, I authorize and consent to medical/hospital care/treatment to be performed by a licensed physician/health care provider, hospital or aid car assistant when deemed necessary or advisable by a physician to safeguard my child’s health. I also give my permission for my child to be transported by ambulance or aid car to a hospital for treatment.

4 passport sized pictures of your child:

2 passport sized pictures of both parents/guardian:

Copy of your NIC or Passport

Allergy List (In case of children who have allergies)