Guidestar Center of Silver Spring Registration

3547 Georgia Avenue, Silver Spring, Maryland 20901

You MUST Save Progress or Submit before leaving this form or ALL entries will be lost.

Child

Please enter the child's full name (example: use Joseph not Joe)

First name *

Middle names

Last name *

Preferred name 🛈

Gender *

Male

Female

Date of birth * +

Language spoken at home *

Grade *

Street address *

City *

State *

Zip Code *

Program

Please select the school year, location, duration, days of attendance, and times for your child

Full day: 8:30 am -5:00 pm; Morning: 8:30 am - 12:30 pm; Afternoon: 1:00 pm - 5:00 pm

Early arrival: 5:00 am - 8:30 am; Late departure: 5:00 pm - 8:30 pm

School year

Location

Rockville

Silver Spring

Gaithersburg

Arrive

Depart

Duration

Full day

Morning

Afternoon

Extended hours

Early arrival

Late departure

Summer program

Summer

Select the days you want your child to attend our summer program each week.

There is no summer program on Independence Day, July 4

Office use only - this section will not be visible to parents

Class

Enrollment date +

Withdrawal date +

Deposit amount

Deposit type

Pending

Credit card

Check # Check #

Tuition

Tuition schedule

Annual

Semi-annual

Monthly

Weekly

Parent or legal guardian

Title * 🛈

First name *

Last name *

Relationship to child *

Street address *

City *

State *

Zip Code *

Enter telephone numbers as 10 digits with no other characters

Include work telephone if applicable

Primary telephone *

Type *

Email address *

Second telephone

Type

Third telephone

Type

Employer

Employer address

Second parent or legal guardian

Title 🛈

First name

Last name

Relationship to child

Street address

City

State

Zip Code

Enter telephone numbers as 10 digits with no other characters

Include work telephone if applicable

Primary telephone

Type

Email address

Second telephone

Type

Third telephone

Type

Employer

Employer address

Other members of your family or household

Please enter the names of siblings and their birth dates.

Name

Date of birth +

Name

Date of birth +

Name

Date of birth +

Name

Date of birth +

Name

Date of birth +

Name

Date of birth +

Other household members

Please list other household members including frequent caregivers.

Name

Relationship

Name

Relationship

Name

Relationship

Name

Relationship

Authorizations

Image authorization

Check yes to authorize us to use photographs and videos of your child on our website, social media page, and in our promotional materials. No child’s name will be published alongside the images.

Image authorization *

Yes

Sunscreen and insect repellent authorization

Check yes to authorize application of non-prescription over-the-counter (OTC) sunscreen or insect repellent to your child. Enter names of products you will supply for us to use.

Sunscreen authorization * 🛈

Yes Yes

Insect repellent authorization * 🛈

Yes Yes

Activity authorization

Check yes to authorize your child's participation in the following activities

Field trip authorization *

Yes

Walk home authorization *

Yes

Wading pool authorization *

Yes

Sprinklers authorization *

Yes

Swimming pool authorization *

Yes

Release for pickup authorization

In addition to parents or legal guardians listed above, I authorize my child to be released to the following for pickup

Enter telephone numbers as 10 digits with no other characters

Authorized pickup name

Relationship to child

Telephone

Address

Authorized pickup name

Relationship to child

Telephone

Address

Authorized pickup name

Relationship to child

Telephone

Address

Authorized pickup name

Relationship to child

Telephone

Address

Emergency contacts

The following individuals are authorized to aid my child in emergency situations when parents or legal guardians cannot be contacted.

Enter telephone numbers as 10 digits with no other characters

Emergency contact name *

Relationship to child *

Telephone *

Telephone

Emergency contact name

Relationship to child

Telephone

Emergency contact name

Relationship to child

Telephone

Emergency contact name

Relationship to child

Telephone

Emergency contact name

Relationship to child

Telephone

Emergency contact name

Relationship to child

Telephone

Emergency medical contacts

Physician name *

Physician telephone *

Physician address *

Dentist name

Dentist telephone

Dentist address

Hospital name

Hospital telephone

Hospital address

Medical information

Complete as appropriate. If none enter none.

Allergies *

Current medications *

Medical conditions *

Developmental concerns *

Special needs *

Dietary requirements *

Activity limitations *

Anything else *

Health forms

The State of Maryland requires a 2 page Health Inventory and an Immunization Certificate to be submitted for each enrolled child. For children living in designated at risk areas Maryland also requires a Blood Lead Testing Certificate. At risk areas are listed in the Health Inventory. Click here to download OCC 1215 Health Inventory, DHMH 896 Immunization Certificate, and/or DHMH 4620 Blood Lead Testing Certificate.

Please provide the signature date for the immunization certificate and the dates of the most recent physical examination and most recent flu (influenza) vaccination.

Immunization certificate +

Physical examination 🛈 +

Flu +

Immunization exemption

All children are required to receive immunization vaccines unless they have a state approved exemption. If your child is exempt from state immunization requirements please provide us with the applicable exemption form and check exempt below.

If your child is exempt from receiving varicella vaccine because he/she has had the varicella (chicken pox) disease, please check exempt below.

Immunization *

Required

Exempt

Varicella vaccine *

Required

Exempt

Immunization

For each vaccine listed below, please enter the number of doses your child has received to date as indicated on the child's record of immunization.

Hepatitis B *

DTaP * 🛈

IPV * 🛈

PCV * 🛈

Hib * 🛈

Rotavirus *

Hepatitis A *

MMR * 🛈

Varicella *

HPV * 🛈

Tdap * 🛈

MCV * 🛈

Medical insurance

My child is covered by the medical insurance policy listed below. I accept responsibility for all medical expenses incurred by the child care provider on behalf of my child.

Insurance carrier

Policy number

Group number

Name of policy holder

Medication Administration

This form provides your written consent for us to administer the listed medications. You must also submit a medication administration authorization form signed by a licensed health care provider.

In the side effects field list any possible side effects.

If the medication is to be administered only on an as needed basis then:

(1) in the Time/frequency field write PRN and the frequency of administration when symptoms occur,

(2) in the PRN symptoms field describe the symptoms that require administration of this medication

Medication name

Dose

Route

Time/frequency

PRN symptoms

Side effects

Start +

End +

Medication name

Dose

Route

Time/frequency

PRN symptoms

Side effects

Start +

End +

A Parent’s Guide to Regulated Child Care

Maryland child care regulations require your child care provider to verify that you have access to the consumer education brochure A Parent’s Guide to Regulated Child Care. Click here to access the web page where you may download the brochure in the right hand column.

Please select yes to verify you have been directed to this web site.

Parent's Guide

Yes

Parent or legal guardian signature

I certify that the information I have provided is accurate to the best of my knowledge.

I certify that my electronic signature entered below is legally binding.

Electronic signature *

Signature date * +