UW Childcare Center at Portage Bay

Enrollment and Re-Enrollment

Once offered a spot, please fill out the following.  We will use this information to create final paperwork for you to sign on your first day.  To assist with completing the below information, please review the form before beginning to fill it out.  Information you will need:

1.  Personal information (Names, relationships, contact information)

2.  Emergency contact information (Names, contact numbers, addresses)

3.  Insurance and healthcare provider information (Policy number, provider's contact information)

4.  Child health information (Health history, medications, considerations)

5.  Bank information (If you are a returning family, this is unnecessary)

6.  Immunizations.  If your child is in the Washington State immunizations database, you can also download an auto-generated copy of this form at: https://wa.myir.net/login/.

 

Child's Name
Child's Name
Birth Date
Birth Date
(Address, City, State, Zip)
Parent/Guardian 1's Name
Parent/Guardian 1's Name
(Address, City, State, Zip)
Parent/Guardian 1's Phone Number (Home)
Parent/Guardian 1's Phone Number (Home)
Parent/Guardian 1's Phone Number (Mobile)
Parent/Guardian 1's Phone Number (Mobile)
(Address, City, State, Zip)
Parent/Guardian 2's Name
Parent/Guardian 2's Name
(Address, City, State, Zip)
Parent/Guardian 2's Phone Number (Home)
Parent/Guardian 2's Phone Number (Home)
Parent/Guardian 2's Phone Number (Mobile)
Parent/Guardian 2's Phone Number (Mobile)
(Address, City, State, Zip)
Authorized pick-ups/Emergency Contacts
Mobile (Contact 1)
Mobile (Contact 1)
Home (Contact 1)
Home (Contact 1)
Alternate (Contact 1)
Alternate (Contact 1)
(Address, City, State, Zip)
Contact 1 Authorized for:
Mobile (Contact 2)
Mobile (Contact 2)
Home (Contact 2)
Home (Contact 2)
Alternate (Contact 2)
Alternate (Contact 2)
(Address, City, State, Zip)
Contact 2 Authorized for:
Mobile (Contact 3)
Mobile (Contact 3)
Home (Contact 3)
Home (Contact 3)
Alternate (Contact 3)
Alternate (Contact 3)
(Address, City, State, Zip)
Contact 3 Authorized for:
Others who Live with the Child
Medical Information
Date of Child's Last Physical Exam
Date of Child's Last Physical Exam
Provider's Contact Number
Provider's Contact Number
(Address, City, State, Zip)
Dentist Contact Number
Dentist Contact Number
(Address, City, State, Zip)
Insurance Information
Other Information