OU Child Development Lab Registration Form Step 1 of 6 16% Personal HistoryGenderMaleFemaleStudent Name(Required) First Last Nickname Date of Birth(Required) MM slash DD slash YYYY Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Allergies Illness/Medications (Please List Instructions and a Note from Physician)Father/Guardian Name First Last Occupation Usual Work Hours Occupation Driver's License Number Social Security Number(Required) Education (Highest Grade Completed or Degrees) Email(Required) Cell PhoneWork PhoneHome PhoneOther PhoneEmail(Required) Mother/Guardian Name First Last Usual Work Hours Occupation Driver's License Number Social Security Number Education (Highest Grade Completed or Degrees) Cell PhoneWork PhoneHome PhoneOther PhoneEmail Status of ParentsLiving TogetherLiving ApartPrimary Custody is with First Last Joint Custody Yes No Extended Family InformationChild Care ProviderGrandmotherPaid SitterOther RelativesOtherList All Siblings in Descending Age OrderNameGender (M/F)AgeGrade Add RemoveAdditional Member of Household (Give Number)FriendsRelativesBoardersOthers Add RemoveEmergency Contacts: In the event that we are unable to reach you, please provide at least one LOCAL Emergency contact below.Name First Last Relation to Child Usual Work Hours Work Phone Cell Phone Home Phone Other Phone Email Name First Last Relation to Child Usual Work Hours Work PhoneCell PhoneHome PhoneOther PhoneEmail Child's Pre-Admission RecordName of Child's Doctor First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Authorization I give permission for the child care facility to obtain emergency medical treatment, including emergency transportation, for my child if I cannot be reached immediately. I agree to be responsible for any emergency medical expenses incurred. (If parent/guardian refuses to sign, instructions must be attached stating what procedure the facility is to follow in an emergency.)Person(s) the child may be released to:NameRelationship to ChildAddressTelephone Number Add RemoveDescribe any special needs or instructionsConsent I understand that the Department of Human Resources does not inspect activities away from the child care facility (home or center). The licenses of the child care facility assumes full responsibility for such activities.Activities away from the facility: Yes No Signature of Parent/Guardian(Required)Transportation provided by the facility: Yes No Signature of Parent/Guardian(Required)Swimming/wading activities provided by the facility: Yes No Signature of Parent/Guardian(Required) Child's Medical ReportIn addition to a medical report or medical screening, a Certificate of Immunization (ADPH-F-IMM-50) is required for each child two months to five years of age and for five year olds who are not enrolled in public or private school. Download Form For Physician, Physician's Assistant, Certified Nurse Practitioner Parent AuthorizationWhile your child is enrolled at the CDL, he/she will be involved in a number of special activities for which we need your permission. Please read the following information carefully. You are encouraged to ask for clarification about any statement which is unclear to you. You, of course, have the option of withdrawing permission at any time. Please check options below for continuous authorization:Continuous Authorization(Required) I give permission for my child to go on walks with the classroom teacher and class on Oakwood University's campus. I give permission for my child to be screened for speech and language. I give permission for my child to be screened for hearing. I give permission for my child to be screened for specific educational needs. I give my child permission to be photographed for educational and marketing purposes to further the cause of Christian education. These pictures will be representatives of enriching experiences offered to your child during the school year. I understand that as part of the CDL program, My child's records may be included in research, which evaluates the value of the program. In all cases, confidentiality of individual children's records is maintained. Select AllPick Up AuthorizationI understand that my child will only be sent home with authorized persons who have written consent from parents/ guardians. I authorize the following to pick up my child from the OU Child Development Lab (must be 18 or older with proper ID):Authorized PersonsNamePhone Number Add RemovePlease press the (+) to the right to add additional names.Signature Operating Schedule • Hours of Operation: Monday-Thursday 7:30 am- 5:30 pm; Friday 7:30 am - 12:00 noon. • Late Pick-Up: A late fee 0($1.00 per minute will be charged after closing time. This will be due in cash at time of pick up.Policies • All students must be at least 3 years or age and potty trained before enrolling in the CDL program. • The state of Alabama requires kindergarteners turn 5 years old on or before Sept. l of the enrolling school year. The CDL applies this date requirementfor PreKI and PreK2 as well. • Children experiencing flu like symptoms, vomiting, fever, or other symptoms that may indicate a contagious disease will only be allowed to return to the CDL when a doctor's note is supplied. • Inclement Weather: During inclement weather, the CDL will contact parents through text and email. • Breakfast, Lunch, and Snack will be served Monday-Thursday. Breakfast is the only meal that will be provided on Fridays. • Birthday Celebrations are welcomed at the discretion of the parent Monday-Thursday. • Show and tell is every Friday. Toy weapons are strictly prohibited. Consent(Required) I have read and understood all CDL requirements. I am indicating by signing below that if my child is admitted, I will adhere to the requirements presented above.SignatureRegistration Fee Price: Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Security Code Cardholder Name Δ
