Enrollment Application

Parent/Guardian Information

Preferred PIN Number for checking child in/out
(4 digits, numbers only)

Preferred PIN Number for checking child in/out
(4 digits, numbers only)

Child Information


Child Health Assessment

Does your child have any known allergies or sensitivities to any of the following? (Check all that apply)

Illnesses or Medical Conditions


Consent for Medical Care and Treatment of Children

I give permission that my child may be given first aid/emergency treatment by the childcare licensee and/or staff at Here we grow Child Development Center, located at 12243 South 700 West Draper, UT 84070

When I cannot be contacted, I authorize and consent to medical, surgical and hospital care, treatment and procedures to be performed for my child by a licensed physician, health care provider, hospital or aid care attendant when deemed necessary or advisable by the physician to safeguard my child’s health. I waive my right to informed consent to such treatment. I also give my permission for my child to be transported by ambulance to an emergency center for treatment. I certify under penalty of perjury under the laws of the state of Utah that this information is true and correct.


Emergency Contacts & Authorized Pickup Person

Name
Relationship to Child
Address
Phone Number
Out of State Contact
Relationship to Child
Address
Phone Number

Tuition/Payment Information

Please outline below who is responsible for payment of tuition and fees. Please specify the amount each parent/guardian is responsible for if parents/guardians are divorced/separated and split tuition payments or if tuition payments are the responsibility of an adult other than the parents/guardians listed on this application.