Awesome Daycare Registration

Child's Full Name 学生姓名 *

First

Last

Gender 性别 *

Age (ex. 2.5 YO) 年龄（例如：2.5周岁）

Birth Date 出生年月 *

Intended Start Date 预计开始时间

Which days of the week would you like to begin with? 您希望星期几开始？

Half Day or Full Day? 半天还是全天？

Half Day 半天
Full Day 全天

Primary Language 掌握语言 *

English 英语
Chinese 中文
Other 其他

Home Address 家庭地址

Information about your child that can be useful for us and the doctor in an emergency situation and/or a hospital visit) (Ex. nickname, favorite toy/song/story/snack, how to best comfort the child, special needs etc) 关于学生的其他有用信息（如：学生小名、喜欢的玩具/儿歌/故事/零食，有效安抚的方式、特殊需要等）以及紧急就医联系人/医生

Parent 1 Name 家长1姓名 *

First

Last

Parent 1 Mobile 家长1联系电话 *

Email where you'd like to receive confirmation, information and daycare updates: 邮箱地址（用来接收确认信、各类信息及托班日常更新等) *

List any chronic illness and or physical limitations that the hospital/doctor should know about: (If none, enter none) 列举医院/医生须知晓的学生的各类慢性疾病及（或）肢体障碍，若无请填写“无” *

List all on-going medications: (If none, enter none) 学生正在服用的药品，若无请填写“无” *

List any medical allergies/asthma: (If none, enter none) 学生是否对任何药物过敏？是否患有哮喘？若无请填写“无” *

1st Emergency Contact Name 第一紧急联络人姓名 *

First

Last

1st Emergency Contact Relationship 第一紧急联络人与学生的关系 *

1st Contact Person Preferred Language 第一紧急联络人偏好的沟通语言 *

1st Emergency Contact Mobile Number 第一紧急联络人手机号码 *

2nd Emergency Contact Name 第二联络人姓名

First

Last

2nd Emergency Contact Relationship 第2紧急联络人与学生的关系

2nd Contact Person Preferred Language 第二紧急联络人偏好的沟通语言

2nd Emergency Contact Mobile Number 第2紧急联络人手机号码

Is your child covered by medical insurance: 学生是否有医疗保险 *

Name of Insurance Company (enter "none" if no insurance) 保险公司名称（若无保险则填写“无） *

Preferred Medical Clinic Hospital/Doctor (in case of non-emergency situations) 偏好的就医机构或医生姓名（非紧急的就医情况下） *

Medical Clinic/Hospital Phone Number 诊所/医院电话

Fapiao needed 是否需要发票 *

If I cannot be consulted in an emergency, I hereby give permission to the qualified physician selected by a representative of Awesome Day Care to hospitalize, secure treatment for, and to order injections, anesthesia, and/or surgery for my child. 在紧急情况下，若无法及时联络到我，我特此允许Awesome Day Care代表本人选择具有资质的医疗机构和医生对我的孩子进行安全的治疗，包括注射、麻醉、及（或）手术 *

I give permission 特此授权

I am hereby notified that a Late Payment Charge of 1.5 % per month, will be charged on all school fees that are overdue 我已被告知并知晓，所有逾期未交的学费将收取每月1.5％的滞纳金。 *

I understand 我理解

I hereby give permission to Awesome Day Care staff to conduct general First Aid and CPR on child if needed, while contacting you as soon as possible. 我特此允许Awesome Day Care的员工在必要时，对我的孩子进行急救和心肺复苏，并第一时间联系本人。 *

I give permission 特此授权

I understand that Awesome Kids Club only has a secondary insurance and that all costs for examinations and treatments in connection to a hospital/health care center should be paid and covered by me. 我了解Awesome Kids Club仅负责场地意外险，因此由医院/医疗机构所产生的所有检查及治疗费用将由本人支付。 *

I understand 我理解

I understand Awesome Kids Club and Awesome Day Care often takes photographs or videos of participants during its activities or events. I grant permission without compensation that these photographs or videos may be used in publications, presentations, websites or promotion of Awesome Kid's Club and Awesome Day Care. Awesome Kids Club will not identify me or my child by name, or release any other personal information without additional permission from me. 我了解Awesome Kids Club和Awesome Day Care经常在课程或活动期间为参与者拍照或录像。我同意无偿使用这些照片或视频，以用于Awesome Kids Club和Awesome Day Care的出版物、演示文稿网站或市场活动。未经本人的允许，Awesome Kids Club不会注明我或我的孩子的姓名，并发布任何其他个人信息。 *

I understand 我理解

Notice: All payments are made monthly. Daily payments and discounts are not permitted for days taken off or for government holidays. Days chosen are non-transferable (i.e 3 day schedule, one day missed, asking for another day to make up). Students are required to come on the days for which they have signed up. Full payments for the month are required at the time of payment notice. Failure to pay the monthly fee may result in your child's space being given to other families温馨提示：课程费用将按整月收取，无法给予因个人原因或遇公共假期所造成缺课的折扣。所选参加天数为固定日期（例如：您选择每周参加三天课程，每周必须为固定的三天，无法因个人原因造成的缺席而补课）。请于收到付款通知单后及时完成付款，延迟付款的家庭将无法保证学位。 *

I understand 我理解

Copy of Passport Main Page 护照首页

Click or drag a file to this area to upload.

Copy of Immunization Report 疫苗接种记录(需提供有记录的每一页）

Click or drag files to this area to upload. You can upload up to 5 files.

I have read the above statements, have filled out the form to the best of my knowledge and by clicking "I understand" I consent to the above terms. 我已仔细阅读上述声明并按照实际情况填写表格，点击“我理解”即代表本人同意上述条款 *

I understand 我理解

Name