Sign Up – Robots & Mentors

Complete the following forms to enroll in our program.

Robots and Mentors Sign Up

Contact

Your Contact Info
Day Care Agreement
Emergency Contact/Parental Consent

General Information

Parent Name(s)

Child's Name

School Name

Grade

Payment Type

Parent Email Address

Parent Cell Phone Number

Enrollment Type

Day Care Agreement

Name of Child

Fee Amount

CCIS Copay Amount, if applicable

Per Day/Week

Day Payment to Be Made

Services to Be Provided

Childs Arrival Time

Childs Departure Time

Late Fee

Persons Designated by Parent to Whom Child May Be Released

Extra Services To Be Provided at an Additional Fee if Applicable

Received Completed Written Program Information at the Time of Enrollment (With Applicable Codes)

Agree To Update the Emergency Contract / Parental Consent Form Information Whenever Changes Occur or Every 6 Months at a Minimum (With Applicable Codes)

Parent/Guardian Signature

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Parent/Guardian Signature Date

Emergency Contact/Parental Consent

Child's Information

Child's Name

Child's Date of Birth

Child's Home Address

Parent/Guardian Information

Parent/Guardian Name

Home Phone

Home Address

Business Name

Business Address

Business/Work Phone Number

Parent/Legal Guardian #2 Name

Parent #2 Home Telephone number

Parent #2 Home Address

Parent #2 Business Name

Parent #2 Business Telephone Number

Parent #2 Business Address

Emergency Contact Persons

First Person's Name

First Person's Telephone Number When Child Is in Care

Second Person's Name

Second Person's Telephone Number When Child Is in Care

Persons to Whom Child May Be Released

First Person's Name

First Person's Address

First Person's Telephone Number When Child Is in Care

Second Person's Name

Second Person's Address

Second Person's Telephone Number When Child Is in Care

Child's Physician/Medical Care Provider

Name

Telephone Number

Address

Special Disabilities (if any)

Allergies (including medical reaction)

Medical or Dietary Information Necessary in an Emergency Situation

Medication, Special Situation

Health Insurance Coverage for Child or Medical Assistance Benefits

Policy Number

Parent Signature Required for Each Item Below To Indicate Parental Consent

Obtaining Emergency Medical Care

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Walks and Trips

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Transportation by the Facility

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Administration of Minor First Aid Procedures

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Swimming

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Wading

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