Guidestar Early Education Center Registration

3547 Georgia Avenue, Silver Spring, Maryland 20901

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Child

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 *

Street address *

City *

State *

Zip Code *

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

Class

Enrollment date +

Withdrawal date +

Program

Select the school year, location, days, and times your child will attend

School year

Location

Rockville

Silver Spring

Gaithersburg

Days

Arrive

Depart

Select the meals your child will be served while in care

Meals

Summer program

Select the summer year, days, and weeks you want your child to attend our summer program

Summer

Summer days

Summer weeks

Parent or legal guardian

First parent or guardian

Child lives with this parent or 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 *

Cell phone carrier: Select your cell phone carrier from the list to enable us to inform you of schedule changes and other events via text message. Messages will be sent to the first cell phone listed.

Cell phone carrier

Second parent or legal guardian

State licensing regulations require that all appropriate fields in this section be completed in full if your child has a surviving second parent or legal guardian.

Second parent or guardian

Child lives with this parent or guardian

No surviving 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 *

Cell phone carrier: Select your cell phone carrier from the list to enable us to inform you of schedule changes and other events via text message. Messages will be sent to the first cell phone listed.

Cell phone carrier

Authorizations

Image authorization: Check yes to authorize our use of 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

No

Skin product authorizations: Check yes to authorize application of non-prescription over-the-counter (OTC) sunscreen and insect repellent to your child. Parents must provide the products in the original container, labeled with the child's name. Enter the names of the products you will provide. Skin products will be applied according to the manufacturer's instructions and will not be used beyond the expiration date of the product.

Sunscreen authorization *

No

Yes Yes

Insect repellent authorization *

No

Yes Yes

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

Field trip authorization *

Yes

No

Walk home authorization *

Yes

No

Wading pool authorization *

Yes

No

Sprinklers authorization *

Yes

No

Swimming authorization *

Yes

No

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

I authorize the following individuals 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

Address *

Emergency contact name

Relationship to child

Telephone

Address

Emergency contact name

Relationship to child

Telephone

Address

Emergency contact name

Relationship to child

Telephone

Address

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 *

Emergency medical instructions

Signs or symptoms to look for *

If signs or symptoms appear do this *

To prevent incidents *

Other procedures: other special medical procedures that may be needed

Other procedures *

Comments *

Health forms: The State of Maryland requires a 2 page Health Inventory and an Immunization Certificate to be submitted for each enrolled child. The state also requires parents to submit documentation that, as required by COMAR 10.11.04, each child has received a lead test when the child is 12 months old and again when the child is 24 months old, regardless of where the child resides, if the child was born on or after January 1, 2015. Click here to download OCC 1215 Health Inventory, DHMH 896 Immunization Certificate, and/or DHMH 4620 Blood Lead Testing Certificate.

If your child requires an Allergy Action Plan or a Medication Administration Authorization Form, click here to download the forms which must be completed and signed by parents and a physician.

Enter the signature date for the immunization certificate and the dates of the most recent physical examination, most recent flu (influenza) vaccination, and tetanus vaccination.

Immunization certificate +

Physical examination 🛈 +

Flu +

Tetanus +

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, 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, check exempt below.

Immunization *

Required

Exempt

Varicella vaccine *

Required

Exempt

Immunization: For each vaccine listed below, 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 * 🛈

Varicella * 🛈

Hepatitis A *

MMR * 🛈

Rotavirus *

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 *

Other members of your family or household

Enter the names of siblings and their birth dates.

Sibling name

Date of birth +

Sibling name

Date of birth +

Sibling name

Date of birth +

Sibling name

Date of birth +

Sibling name

Date of birth +

Sibling name

Date of birth +

Other household members: List other household members including frequent caregivers.

Household member name

Relationship

Household member name

Relationship

Household member name

Relationship

Household member name

Relationship

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 Guide to Regulated Child Care. Click here to access the web page where you may download the brochure in the right hand column.

Guide *

I have received the brochure Guide to Regulated Child Care

Parent or legal guardian signature

Emergency medical authorization: I authorize the child care center to obtain medical care for my child in the event of a medical emergency. This authorization includes transportation for medical care and any medical care determined appropriate by medical personnel.

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

Electronic signature *

Signature date * +

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