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)
Gender *
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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
Location
Days
Duration
Extended hours
Meals 🛈
Supplementary programs 🛈

Summer program

Select the days you want your child to attend our summer program each week.
There is no summer program on Independence Day, July 4
Week 1
Week 2
Week 3
Week 4
Week 5

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

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Deposit type
 
Tuition schedule

Parent or legal guardian

Enter telephone numbers as 10 digits with no other characters
Include work telephone if applicable

Second parent or legal guardian

Enter telephone numbers as 10 digits with no other characters
Include work telephone if applicable

Other members of your family or household

Please enter the names of siblings and their birth dates.
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Other household members
Please list other household members including frequent caregivers.

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 *
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 * 🛈
 
Insect repellent authorization * 🛈
 
Activity authorization
Check yes to authorize your child's participation in the following activities
Field trip authorization *
Walk home authorization *
Wading pool authorization *
Sprinklers authorization *
Swimming pool authorization *

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

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 medical contacts

Medical information

Complete as appropriate. If none enter none.
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.
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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 *
Varicella vaccine *
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.
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.
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
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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

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.
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