Children's Learning Center Application, USI

Children's Learning Center Application

Please fill this form out as completely as possible. This is the information we
use to locate you in case of emergency, as well as monitoring who is allowed
to access your child.

Family Information:

Mother's Name:

Father's Name:

Guardian's Name (if living with guardian):

Child's Full Name:

Child Birthday:

Child Gender:

Child Lives With:

Child Primary Address:

City

State

Zip Code

Mother or Guardian Work :

Work Number:

Mother Cell Number:

Mother Email Address:

Father or Guardian Work:

Father Work Number:

Father Cell Number:

Father Email Address:

Child's Medical Information:

Name of Insurance Company:

Policy Owner:

Policy Number:

Physician Name:

Physician Phone Number:

Physician Address:

City

State

Zip Code

Hospital Preference:

Child Drug Allergies? Please List:

Child Food Allergies? Please List:

Dental Insurance Company:

Policy Owner:

Policy Number:

Dentist Name:

Dentist Address:

City

State

Zip Code

Dentist Phone Number:

Emergency Release Form:

I, (We) , of City , State , County , am/are the parent(s) of , born, , who resides at the previous address. I (we) authorize the USI Children's Learning Center Staff to seek and consent to medical treatment at a hospital or minor emergency center in the state of Indiana. I (We) authorize use of this form from to (dates).

Emergency Contacts:

Contact #1 Name:

Address:

City

State

Zip Code

Home Number:

Cell Number:

Email Address:

Contact #2 Name:

Address:

City

State

Zip Code

Home Number:

Cell Number

Email Address:

Contact #3 Name:

Home Number:

Cell Number:

Email Address:

Authorized Individuals to Pick up Your Child:

Person #1 Name:

Relationship to Child:

Home Number:

Work Number:

Cell Number:

Person #2 Name:

Relationship to Child:

Home Number:

Cell Number:

Person #3 Name:

Relationship to Child:

Home Number:

Cell Number:

Person #4 Name:

Relationship to Child:

Home Number:

Cell Number:

Red Alert Evacuation Plan:

In view of our unsettled times we feel there is a need to make you aware of the center's emergency evacuation plan.

Already in place are the arrangements to take the children to the lower level of the Health Professions in case there is a need to evacuate the Children's Center. We are in the process of securing two locations, one east and one west of the university, that we would use in the extreme case that we would have to evacuate the campus. Please fill in the form below to give permission to the childrens center staff to transport your child in whatever manner we feel is safe. This plan will be implemented only in the case of an emergency where the safety of your child depends on evacuating our campus. Our west evacuation location is St. Paul's UCC Church at 2227 West Michigan St. The phone number there is 812-425-1522. If for some reason we would not be able to go east on Highway 62, we would go west to Children's Learning Center of Mt. Vernon, 2100 W. 4th Street, Mt. Vernon (west of town near the Mt. Vernon Ford Dealership on Highway 62). Their phone number is 812-838-3312 If you have any questions or concerns please let us know. Please make a record of the locations and phone numbers.

In the case of an emergency requiring the University of Southern Indiana campus to be evacuated, I give permission for my child (Child Name) to be transported in a safe manner to St. Paul's United Church of Christ, 2227 West Michigan or Children's Learning Center of Mt. Vernon 2100 W. 4 St. Mt. Vernon, Indiana St. Paul's UCC would be the first choice. If we could not go east from the university, we would then go to the Mt. Vernon location).

Parent(s) or Guardian(s):		Date:	/
Parent(s) or Guardian(s):		Date:	/

By submitting this online application: you agree to the terms and conditions of the Children's Learning Center, USI and consent to the permissions stated in this form.

8600 University Boulevard - Evansville, IN 47712-3596 - 812/464-8600