Evergreen Learning Center Enrollment Form

This form may take between 30-45 minutes to complete. Please set aside the full amount of time to complete the enrollment form in one sitting to not risk losing your progress.

Child's Information

Child's Full Name

Name Child Goes By

Gender

Male

Female

Date of Birth

Age of Child by September 1st 2024

Street Address

City

State

Zip

Parent / Guardian Information

Parent / Guardian Name

Relationship to Child

Parent / Guardian Street Address

Parent / Guardian City

Parent / Guardian State

Parent / Guardian State Zip

Parent / Guardian Cell

Employer

Work Hours

Work Phone

Parent / Guardian Email Address

Secondary Parent / Guardian Name

Relationship to Child

2nd Parent / Guardian Street Address

2nd Parent / Guardian Street City

2nd Parent / Guardian State

2nd Parent / Guardian Street Zip

2nd Parent / Guardian Cell

2nd Parent / Guardian Employer

2nd Parent / Guardian Work Hours

2nd Parent / Guardian Work Phone

2nd Parent / Guardian Email Address

Emergency Contact

Please list any additional emergency contacts authorized to act for the parents / guardians in case of an emergency.

Emergency Contact Name

Contact's Relationship to Child

Cell

Second Emergency Contact Name

Second Contact's Relationship to Child

Second Contact's Cell

Pick-up Authorization

Please list any additional contacts, other than parents/guardians and emergency contacts, authorized to pick-up your child:

Person 1 Name:

Person 1 Cell:

Person 2 Name:

Person 2 Cell:

Person 3 Name:

Person 3 Cell:

Person 4 Name:

Person 4 Cell:

Family Information

Does this child live in the home with both parents?

Yes

No

If not, please describe the custody of guardianship agreement:

Please list all adults living in the child's household(s) and their relationship to the child (parents, grandparents, etc.).

Adult 1

Adult 1 Relationship to Child

Adult 2

Adult 2 Relationship to Child

Adult 3

Adult 3 Relationship to Child

Adult 4

Adult 4 Relationship to Child

Please list any other children in the family.

Child 1 Name:

Child 1 DOB:

Child 1 School:

Child 2 Name:

Child 2 DOB:

Child 2 School:

Child 3 Name:

Child 3 DOB:

Child 3 School:

Child 4 Name:

Child 4 DOB:

Child 4 School:

Is there anything else we should know about your child's family?

Media Consent

Please Understand: Your child will be photographed but images will not be shared publicly without your permission. Our staff will share photos of students (no names) in private social media groups accessed by ELC parents and staff.

ELC has permission to photograph my child during participation in programming for use in publications, promotional material and/or training videos

Yes

No

Child's Medical Information

Does your child have any medical condition(s) that require ongoing care?

Yes

No

If yes, please explain what type of care is administered at home and by who?

Are you reguesting that this care be provided at the facility

Yes

No

If yes, describe the care required

List any allergies, indicating the severity (foods, medications, seasonal etc.).

Does your child require an EpiPen?

Yes

No

If yes, for what?

List any medications your child is currently taking and the dosage.

Please list anything else we should know.

Name of Pediatrician

Doctor's Office

Office Address

Pediatrician's Phone #

Child Personality Development

At what age did your child crawl?

What age did your child walk?

What are some of your child's favorite things to play at home?

Does your child have special interests?

Anything else we should know?

Eating Habits

Only fill out this section if your child is an infant.

Check all that apply: I plan to...

Provide formula

Provide pumped breastmilk

Sit in the facility to breastfeed

If formula will be used, what kind of formula?

If a bottle will be used, how much does your child typically drink in one sitting?

Describe your child's typical feeding schedule:

Is there anything else we should know?

Only fill out this section if your child is eating solid food

Does your child feed him/herself?

Yes

No

What is your child's typical eating schedule for Breakfast, Lunch, Dinner, & Snack:

What is your child's general attitude towards eating?

List below foods your child should avoid (allergies, intolerance, cultural/religious preferences).

Favorite foods:

Food dislikes:

Should we know anything else?

Sleeping Habits

Typical Bedtime:

Morning Wake-up Time:

Average number of hours of sleep per night:

Describe your child's typical nap schedule with time(s) and duration(s):

What is your child's typical attitude towards napping/bedtime?

Habits associated with going to sleep:

Is bed wetting an issue?

Yes

No

If yes, is it an issue at nap or bed time?

Are there any other sleep related habits we should know?

Toileting Habits

Children in the 3 year old and 4 year old class must be fully potty trained.

Is your child mostly potty trained when awake (fewer than 2 accidents per week)?

Yes

No

Is your child mostly potty trained, even during naps/overnight (fewer than 2 accidents per week)?

Yes

No

Can your child tell when he/she needs to go?

Yes

No

Can your child use the restroom on their own?

Yes

No

What word does your child use for urinating?

What word does your child use for bowel movements?

Is there anything else we should know about toileting habits?

Parent / Guardian Declarations

Upon receipt of the Parent Handbook I agree to follow all of the policies.

I agree that at least one parent will attend both Parenting Resource Events on 9/16/2024 and 2/6/2024.

My child is up-to-date on their immunizations. I have or will submit an up-to-date certification of immunization or a letter of exemption.

I hereby authorize emergency medical care for my child. In the event of an accident or illness, I grant permission to the Evergreen Learning Center staff or representatives to administer necessary first aid and/or call an ambulance to take my child to the nearest medical facility for additional care.

Child Care Agreement

Our Promise to you

Provide a loving, nurturing and supportive environment for children.
Offer opportunities for children to grow cognitively, emotionally, socially, and physically.
Communicate pertinent information with you about your child and our program.

Your Promise to us

Follow all established Evergreen Learning Center policies and procedures.
Follow payment procedures in a timely and accurate manner.
Read and discuss rules and updates with your child.
Inform us of any changes in registration information, attendance, or payment options.

Parent / Guardian Signature

A $50 non-refundable registration fee must be submitted with this contract.

Name of Parent / Guardian

I have read the above terms and understand that by signing, I agree to follow the terms of the contract.

Today's Date

Evergreen Learning Center Enrollment Form

Child's Information

Parent / Guardian Information

Emergency Contact

Pick-up Authorization

Family Information

Media Consent

Child's Medical Information

Child Personality Development

Eating Habits

Sleeping Habits

Toileting Habits

Parent / Guardian Declarations

Child Care Agreement

Parent / Guardian Signature

918.369.6400

agamble@evergreenbc.org

Service Times
Sunday: 9am & 10:30am
Wednesday: 6:30pm

©2021 Evergreen Baptist Church Privacy Policy

Evergreen Church
10301 East 111th Street S.
Bixby, OK 74008

Ph: (918) 369-6400 | Fax: (918) 369-6405

Evergreen Learning Center Enrollment Form

Child's Information

Parent / Guardian Information

Emergency Contact

Pick-up Authorization

Family Information

Media Consent

Child's Medical Information

Child Personality Development

Eating Habits

Sleeping Habits

Toileting Habits

Parent / Guardian Declarations

Child Care Agreement

Parent / Guardian Signature

918.369.6400

agamble@evergreenbc.org

Service TimesSunday: 9am & 10:30amWednesday: 6:30pm

©2021 Evergreen Baptist Church Privacy Policy

Evergreen Church10301 East 111th Street S.Bixby, OK 74008 Ph: (918) 369-6400 | Fax: (918) 369-6405

Service Times
Sunday: 9am & 10:30am
Wednesday: 6:30pm

Evergreen Church
10301 East 111th Street S.
Bixby, OK 74008

Ph: (918) 369-6400 | Fax: (918) 369-6405