Registration Form

Child's Information

At least 200x200 px
Parent(s)/Guardian(s) - At least one parent/guardian is required
This field is encrypted
This field is encrypted
Additional Parent/Guardian Information
Other members of the family living at home
Name Age Relationship
Emergency Information
Two people to contact if parents cannot be reached:
Contact #1
Contact #2
Developmental History
  1. The child day center agrees to notify parent(s)/guardian(s) whenever the child becomes ill and parent(s)/guardian(s) will arrange to have the child picked up as soon as possible if so requested by the center.
  2. The parent(s)/guardian(s) authorize the child day center to obtain immediate medical care if any emergency occurs when the parent(s)/guardian(s) cannot be located immediately. ‡
  3. The parent(s)/guardian(s) agree to inform the center within 24 hours or the next business day after his child or any member of the immediate household has developed a reportable communicable disease, as defined by the State Board of Health, except for life threatening diseases which must be reported immediately.
  4. Registration is non-refundable.
  5. By submitting this form, the parent(s) agree to the policies explained in the Parent Handbook.

† Appropriate paperwork, such as custody paperwork, shall be attached if a parent is not allowed to pick up the child.
NOTE: Section 22.1-4.3 of the Code of Virginia states that unless a court order has been issued to the contrary, the noncustodial parent of a student enrolled in a public school or day care center must be included, upon the request of such noncustodial parent, as an emergency contact for events occurring during school or day care activities.

‡ If there is an objection to seeking emergency medical care, a statement should be obtained for the parent(s) or guardian(s) that states the objection and the reason for the objection.

Proof of the child's identity and age may include a certified copy of the child's birth certificate, birth registration card, notification of birth (hospital, physician or midwife record), passport, copy of placement agreement or other proof of the child's identity from a child placing agency (foster care and adoption agencies), record form a public school in Virginia, certification by a principal or his designee of a public school in the U.S. that a certified copy of the child's birth record was previously presented or copy of the entrustment agreement conferring temporary legal custody of a child to an independent foster parent. Viewing the child's proof of identity is not necessary when the child attends a public school in Virginia and the center assumes responsibility for the child directly from the school (i.e., after school program) or center transfers responsibility of the child directly to the school (i.e., before school program). While programs are not required to keep the proof of the child's identity, documentation of viewing this information must be maintained for each child.

Section 63.2-1809 of the Code of Virginia states that the proof of identity, if reproduced or retained by the child day program or both, shall be destroyed upon the conclusion of the requisite period of retention. The procedures for disposal, physical destruction or other disposition of the proof of identity containing social security numbers shall include all reasonable steps to destroy documents my (i) shredding, (ii) erasing, (iii) otherwise modifying the social security numbers in those records to make them readable or indecipherable by any means.

Upcoming Events

10/08/2019 - Cullipher Farms Cullipher Farms field trip. Preschool B through Kindergarten The buses will leave promptly at 9:15AM Send a bagged lunch read more
10/25/2019 - Fall Parade & Party Book Character Parade and Party 11:30AM -1:00PM read more
11/01/2019 - Conferences: School Closed Parent teacher conferences School closed to students read more
11/11/2019 - Veteran's Day-School Closed read more


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