Common use of Discrimination Policy Clause in Contracts

Discrimination Policy. Xxxxxxxx Day School admits students of any race, color, national and ethnic origin to all the rights, privileges, programs, and activities generally accorded or made available to students at this school. It does not discriminate based on race, color, national and ethnic origin in administration of its educational policies and admissions policies. PARENT(S) SIGNED: Parent/Guardian Date SIGNED: Parent/Guardian Date CENTER SIGNED: Center Representative Date Family Registration Child Information (One per family) 1st Child Last Name First Name M.I. Nickname Entering grade Male Female Birth Date Birth City/State Existing medical conditions, medications and/or special attention your child may require Allergies Pediatrician's Name Phone Address Photo/Video: Pictures and/or video may be posted in classrooms, bullitin boards, worship screens, newsletters, website and/or social media. Do we have authorization to take/use your child's photo/video in the following ways? Class/School Projects Yes No School Newsletter Yes No Xxxxxxxx Baptist Church/Day School Media Yes No 2nd Child Last Name First Name M.I. Nickname Entering grade Male Female Birth Date Birth City/State Existing medical conditions, medications and/or special attention your child may require Allergies Pediatrician's Name Phone Address Photo/Video: Pictures and/or video may be posted in classrooms, bulletin boards, worship screens, newsletters, website and/or social media. Do we have authorization to take/use your child's photo/video in the following ways? Class/School Projects Yes No School Newsletter Yes No Xxxxxxxx Baptist Church/Day School Media Yes No 3rd Child Last Name First Name M.I. Nickname Entering grade Male Female Birth Date Birth City/State Existing medical conditions, medications and/or special attention your child may require Allergies Pediatrician's Name Phone Address Photo/Video: Pictures and/or video may be posted in classrooms, bulletin boards, worship screens, newsletters, website and/or social media. Do we have authorization to take/use your child's photo/video in the following ways? Class/School Projects Yes No School Newsletter Yes No Xxxxxxxx Baptist Church/Day School Media Yes No Additional Comments & Information: Family Registration, continued Parent/Guardian Information Primary Parent (s) 1st Parent/Guardian Last Name First Name M.I. Relationship to Child Email Address ( Individuals) Work Phone Cell Phone Provider Home Resident Street Address Apt: City Zip Code Mailing Address (if different than above: Apt: City Zip Code Occupation Employer Work Address Hours 2nd Parent/Guardian Last Name First Name M.I. Relationship to Child Email Address ( Individuals) Work Phone Cell Phone Provider Home Resident Street Address Apt: City Zip Code Mailing Address (if different than above: Apt: City Zip Code Occupation Employer Work Address Hours Which Guardian Should be Called First? Additional Parent/Guardian Information Non-primary Parent/Guardian Last Name First Name M.I. Relationship to Child Email Address ( Individuals) Work Phone Cell Phone Provider Home Resident Street Address Apt: City Zip Code Mailing Address (if different than above: Apt: City Zip Code Emergency Contact and Authorized Pickups 1st Contact/Pickup Last Name First Name Relationship to Child Home Phone Cell Phone Able to pick up all children in the family Not able to pick up the following children: 2nd Contact/Pickup Last Name First Name Relationship to Child Home Phone Cell Phone Able to pick up all children in the family Not able to pick up the following children: 3rd Contact/Pickup Last Name First Name Relationship to Child Home Phone Cell Phone Able to pick up all children in the family Not able to pick up the following children: Additional Comments and Information that may be helpful Signature Parent/Guardian Signature Date State of California – Health and Human Services Agency California Department of Social Services‌ IDENTIFICATION AND EMERGENCY INFORMATION CHILD CARE CENTERS/FAMILY CHILD CARE HOMES To Be Completed by Parent or Authorized Representative CHILD’S NAME LAST MIDDLE FIRST SEX TELEPHONE ( ) ADDRESS NUMBER STREET CITY STATE ZIP BIRTHDATE PARENT / AUTHORIZED REPRESENTATIVE NAME LAST MIDDLE FIRST BUSINESS TELEPHONE ( ) HOME ADDRESS NUMBER STREET CITY STATE ZIP HOME TELEPHONE ( ) PARENT / AUTHORIZED REPRESENTATIVE NAME LAST MIDDLE FIRST BUSINESS TELEPHONE ( ) HOME ADDRESS NUMBER STREET CITY STATE ZIP HOME TELEPHONE ( ) PERSON RESPONSIBLE FOR CHILD LAST MIDDLE FIRST HOME TELEPHONE ( ) BUSINESS TELEPHONE ( ) ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCY NAME ADDRESS TELEPHONE RELATIONSHIP PHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCY PHYSICIAN ADDRESS MEDICAL PLAN AND NUMBER TELEPHONE ( ) DENTIST ADDRESS MEDICAL PLAN AND NUMBER TELEPHONE ( ) IF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN? CALL EMERGENCY HOSPITAL OTHER EXPLAIN: LIC 700 (10/19) (CONFIDENTIAL) Page 1 of 2 State of California – Health and Human Services Agency California Department of Social Services NAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY (CHILD WILL NOT BE ALLOWED TO LEAVE WITH ANY OTHER PERSON WITHOUT WRITTEN AUTHORIZATION FROM PARENT OR AUTHORIZED REPRESENTATIVE) NAME RELATIONSHIP TIME CHILD WILL BE PICKED UP SIGNATURE OF PARENT/GUARDIAN OR AUTHORIZED REPRESENTATIVE DATE TO BE COMPLETED BY FACILITY DIRECTOR/ADMINISTRATOR/FAMILY CHILD CARE HOMES LICENSEE DATE OF ADMISSION LAST DATE OF ENROLLMENT LIC 700 (10/19) (CONFIDENTIAL) Page 2 of 2 State of California – Health and Human Services Agency California Department of Social Services‌ INDIVIDUAL INFANT SLEEPING PLAN Date of plan: SECTION A: INFANT’S INFORMATION Infant’s Name Gender Birth Date Authorized Representative’s Name (Primary Contact) Phone Number Authorized Representative’s Name (Secondary Contact) Phone Number

Discrimination Policy. Xxxxxxxx Day School admits students of any race, color, national and ethnic origin to all the rights, privileges, programs, and activities generally accorded or made available to students at this school. It does not discriminate based on race, color, national and ethnic origin in administration of its educational policies and admissions policies. PARENT(S) SIGNED: Parent/Guardian Date SIGNED: Parent/Guardian Date CENTER SIGNED: Center Representative Date Family Child Registration Child Information (One per family) 1st Child Last Name First Name M.I. Nickname Entering grade Male Female Birth Date Birth City/State Existing food restrictions, medical conditions, medications and/or special attention your child may require Allergies Pediatrician's Name Phone Address Photo/Video: Pictures and/or video may be posted in classrooms, bullitin boards, worship screens, newsletters, website and/or social media. Do we have authorization to take/use your child's photo/video in the following ways? Class/School Projects Yes No School Newsletter Yes No Xxxxxxxx Baptist Church/Day School Media Yes No 2nd Child Last Name First Name M.I. Nickname Entering grade Male Female Birth Date Birth City/State Existing medical conditions, medications and/or special attention your child may require Allergies Pediatrician's Name Phone Address Photo/Video: Pictures and/or video may be posted in classrooms, bulletin boards, worship screens, newsletters, website and/or social media. Do we have authorization to take/use your child's photo/video in the following ways? Class/School Projects Yes No School Newsletter Yes No Xxxxxxxx Baptist Church/Day School Media Yes No 3rd Child Last Name First Name M.I. Nickname Entering grade Male Female Birth Date Birth City/State Existing medical conditions, medications and/or special attention your child may require Allergies Pediatrician's Name Phone Address Photo/Video: Pictures and/or video may be posted in classrooms, bulletin boards, worship screens, newsletters, website and/or social media. Do we have authorization to take/use your child's photo/video in the following ways? Class/School Projects Yes No School Newsletter Yes No Xxxxxxxx Baptist Church/Day School Media Yes No Additional Comments & Information: Family Registration, continued Parent/Guardian Information Primary Parent (s) 1st Parent/Guardian Last Name First Name M.I. Relationship to Child Email Address ( Individuals) Work )* we email all statements Cell Phone Cell Phone Provider Home Resident Street Address Apt: City Zip Code Mailing Address (if different than above: Apt: City Zip Code app purposes) Occupation Employer Work Address Hours 2nd Parent/Guardian Last Name First Name M.I. Relationship to Child Email Address ( Individuals) Work )* we email all statements Cell Phone Cell Phone Provider Home Resident Street Address Apt: City Zip Code Mailing Address (if different than above: Apt: City Zip Code app purposes) Occupation Employer Work Address Hours Which Guardian Should be Called First? Additional Parent/Guardian Information Non-primary Parent/Guardian Last Name First Name M.I. Relationship to Child Email Address ( IndividualsBilling Information- Payments can be made online at xxxxxxxxx.xxx Billing Schedule Weekly Billing Monthly Billing (includes a 5% discount when paid by 5th of month) Work Phone Cell Phone Provider Home Resident Street Address AptFood Restriction: City Zip Code Mailing Address If you noted a food restriction above, please explain (if different than aboveie: AptDairy or eggs: City Zip Code Emergency Contact and Authorized Pickups 1st Contact/Pickup Last Name First Name Relationship to Child Home Phone Cell Phone Able to pick up None at all children in the family Not able to pick up the following children: 2nd Contact/Pickup Last Name First Name Relationship to Child Home Phone Cell Phone Able to pick up all children in the family Not able to pick up the following children: 3rd Contact/Pickup Last Name First Name Relationship to Child Home Phone Cell Phone Able to pick up all children in the family Not able to pick up the following children: or allowed as an ingredient) Additional Comments and Information that may be helpful Signature Parent/Guardian Signature Date State of California – Health and Human Services Agency California Department of Social Services‌ IDENTIFICATION AND EMERGENCY INFORMATION CHILD CARE CENTERS/FAMILY CHILD CARE HOMES To Be Completed by Parent or Authorized Representative CHILD’S NAME LAST MIDDLE FIRST SEX TELEPHONE ( ) ADDRESS NUMBER STREET CITY STATE XXXXXX XXXXXX XXXX XXXXX ZIP BIRTHDATE PARENT / AUTHORIZED REPRESENTATIVE NAME LAST MIDDLE FIRST BUSINESS TELEPHONE ( ) HOME ADDRESS NUMBER STREET CITY STATE XXXXXX XXXXXX XXXX XXXXX ZIP HOME TELEPHONE ( ) PARENT / AUTHORIZED REPRESENTATIVE NAME LAST MIDDLE FIRST BUSINESS TELEPHONE ( ) HOME ADDRESS NUMBER STREET CITY STATE XXXXXX XXXXXX XXXX XXXXX ZIP HOME TELEPHONE ( ) PERSON RESPONSIBLE FOR CHILD LAST MIDDLE FIRST HOME TELEPHONE ( ) BUSINESS TELEPHONE ( ) ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCY NAME ADDRESS TELEPHONE RELATIONSHIP PHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCY PHYSICIAN ADDRESS MEDICAL PLAN AND NUMBER TELEPHONE ( ) DENTIST ADDRESS MEDICAL PLAN AND NUMBER TELEPHONE ( ) IF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN? CALL EMERGENCY HOSPITAL OTHER EXPLAIN: LIC 700 (10/19) (CONFIDENTIAL) Page 1 of 2 State of California – Health and Human Services Agency California Department of Social Services NAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY (CHILD WILL NOT BE ALLOWED TO LEAVE WITH ANY OTHER PERSON WITHOUT WRITTEN AUTHORIZATION FROM PARENT OR AUTHORIZED REPRESENTATIVE) NAME RELATIONSHIP TIME CHILD WILL BE PICKED UP SIGNATURE OF PARENT/GUARDIAN OR AUTHORIZED REPRESENTATIVE DATE TO BE COMPLETED BY FACILITY DIRECTOR/ADMINISTRATOR/FAMILY CHILD CARE HOMES LICENSEE DATE OF ADMISSION LAST DATE OF ENROLLMENT LIC 700 (10/19) (CONFIDENTIAL) Page 2 of 2 State of California – Health and Human Services Agency California Department of Social Services‌ INDIVIDUAL INFANT SLEEPING PLAN Date of plan: SECTION A: INFANT’S INFORMATION Infant’s Name Gender Birth Date Authorized Representative’s Name (Primary Contact) Phone Number Authorized Representative’s Name (Secondary Contact) Phone Number

Discrimination Policy. Xxxxxxxx Day School admits students of any race, color, national and ethnic origin to all the rights, privileges, programs, and activities generally accorded or made available to students at this school. It does not discriminate based on race, color, national and ethnic origin in administration of its educational policies and admissions policies. PARENT(S) SIGNED: Parent/Guardian Date SIGNED: Parent/Guardian Date CENTER SIGNED: Center Representative Date Family Registration Child Information (One per family) 1st Child Last Name First Name M.I. Nickname Entering grade Male Female Birth Date Birth City/State Existing medical conditions, medications and/or special attention your child may require Allergies Pediatrician's Name Phone Address Photo/Video: Pictures and/or video may be posted in classrooms, bullitin boards, worship screens, newsletters, website and/or social media. Do we have authorization to take/use your child's photo/video in the following ways? Class/School Projects Yes No School Newsletter Yes No Xxxxxxxx Baptist Church/Day School Media Yes No 2nd Child Last Name First Name M.I. Nickname Entering grade Male Female Birth Date Birth City/State Existing medical conditions, medications and/or special attention your child may require Allergies Pediatrician's Name Phone Address Photo/Video: Pictures and/or video may be posted in classrooms, bulletin boards, worship screens, newsletters, website and/or social media. Do we have authorization to take/use your child's photo/video in the following ways? Class/School Projects Yes No School Newsletter Yes No Xxxxxxxx Baptist Church/Day School Media Yes No 3rd Child Last Name First Name M.I. Nickname Entering grade Male Female Birth Date Birth City/State Existing medical conditions, medications and/or special attention your child may require Allergies Pediatrician's Name Phone Address Photo/Video: Pictures and/or video may be posted in classrooms, bulletin boards, worship screens, newsletters, website and/or social media. Do we have authorization to take/use your child's photo/video in the following ways? Class/School Projects Yes No School Newsletter Yes No Xxxxxxxx Baptist Church/Day School Media Yes No Additional Comments & Information: Family Registration, continued Parent/Guardian Information Primary Parent (s) 1st Parent/Guardian Last Name First Name M.I. Relationship to Child Email Address ( Individuals) Work Phone Cell Phone Provider Home Resident Street Address Apt: City Zip Code Mailing Address (if different than above: Apt: City Zip Code Occupation Employer Work Address Hours 2nd Parent/Guardian Last Name First Name M.I. Relationship to Child Email Address ( Individuals) Work Phone Cell Phone Provider Home Resident Street Address Apt: City Zip Code Mailing Address (if different than above: Apt: City Zip Code Occupation Employer Work Address Hours Which Guardian Should be Called First? Additional Parent/Guardian Information Non-primary Parent/Guardian Last Name First Name M.I. Relationship to Child Email Address ( Individuals) Work Phone Cell Phone Provider Home Resident Street Address Apt: City Zip Code Mailing Address (if different than above: Apt: City Zip Code Emergency Contact and Authorized Pickups 1st Contact/Pickup Last Name First Name Relationship to Child Home Phone Cell Phone Able to pick up all children in the family Not able to pick up the following children: 2nd Contact/Pickup Last Name First Name Relationship to Child Home Phone Cell Phone Able to pick up all children in the family Not able to pick up the following children: 3rd Contact/Pickup Last Name First Name Relationship to Child Home Phone Cell Phone Able to pick up all children in the family Not able to pick up the following children: Additional Comments and Information that may be helpful Signature Parent/Guardian Signature Date State of California – Health and Human Services Agency California Department of Social Services‌ IDENTIFICATION AND EMERGENCY INFORMATION CHILD CARE CENTERS/FAMILY CHILD CARE HOMES To Be Completed by Parent or Authorized Representative CHILD’S NAME LAST MIDDLE FIRST SEX TELEPHONE ( ) ADDRESS NUMBER STREET CITY STATE ZIP BIRTHDATE PARENT / AUTHORIZED REPRESENTATIVE NAME LAST MIDDLE FIRST BUSINESS TELEPHONE ( ) HOME ADDRESS NUMBER STREET CITY STATE ZIP HOME TELEPHONE ( ) PARENT / AUTHORIZED REPRESENTATIVE NAME LAST MIDDLE FIRST BUSINESS TELEPHONE ( ) HOME ADDRESS NUMBER STREET CITY STATE ZIP HOME TELEPHONE ( ) PERSON RESPONSIBLE FOR CHILD LAST MIDDLE FIRST HOME TELEPHONE ( ) BUSINESS TELEPHONE ( ) ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCY NAME ADDRESS TELEPHONE RELATIONSHIP PHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCY PHYSICIAN ADDRESS MEDICAL PLAN AND NUMBER TELEPHONE ( ) DENTIST ADDRESS MEDICAL PLAN AND NUMBER TELEPHONE ( ) IF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN? CALL EMERGENCY HOSPITAL OTHER EXPLAIN: LIC 700 (10/19) (CONFIDENTIAL) Page 1 of 2 State of California – Health and Human Services Agency California Department of Social Services NAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY (CHILD WILL NOT BE ALLOWED TO LEAVE WITH ANY OTHER PERSON WITHOUT WRITTEN AUTHORIZATION FROM PARENT OR AUTHORIZED REPRESENTATIVE) NAME RELATIONSHIP TIME CHILD WILL BE PICKED UP SIGNATURE OF PARENT/GUARDIAN OR AUTHORIZED REPRESENTATIVE DATE TO BE COMPLETED BY FACILITY DIRECTOR/ADMINISTRATOR/FAMILY CHILD CARE HOMES LICENSEE DATE OF ADMISSION LAST DATE OF ENROLLMENT LIC 700 (10/19) (CONFIDENTIAL) Page 2 of 2 State of California – Health and Human Services Agency California Department of Social Services‌ INDIVIDUAL INFANT SLEEPING PLAN Date of plan: SECTION A: INFANT’S INFORMATION Infant’s Name Gender Birth Date STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CHILD CARE CENTER NOTIFICATION OF PARENTS’ RIGHTS PARENTS’ RIGHTS As a Parent/Authorized Representative’s Name (Primary Contact) Phone Number Authorized Representative’s Name (Secondary Contact) Phone Number, you have the right to:

Discrimination Policy. Xxxxxxxx Day School admits students of any race, color, national and ethnic origin to all the rights, privileges, programs, and activities generally accorded or made available to students at this school. It does not discriminate based on race, color, national and ethnic origin in administration of its educational policies and admissions policies. PARENT(S) SIGNED: Parent/Guardian Date SIGNED: Parent/Guardian Date CENTER SIGNED: Center Representative Date Family Registration Child Information (One per family) 1st Child Last Name First Name M.I. Nickname Entering grade Male Female Birth Date Birth City/State Existing medical conditions, medications and/or special attention your child may require Allergies Pediatrician's Name Phone Address Photo/Video: Pictures and/or video may be posted in classrooms, bullitin boards, worship screens, newsletters, website and/or social media. Do we have authorization to take/use your child's photo/video in the following ways? Class/School Projects Yes No School Newsletter Yes No Xxxxxxxx Baptist Church/Day School Media Yes No 2nd Child Last Name First Name M.I. Nickname Entering grade Male Female Birth Date Birth City/State Existing medical conditions, medications and/or special attention your child may require Allergies Pediatrician's Name Phone Address Photo/Video: Pictures and/or video may be posted in classrooms, bulletin boards, worship screens, newsletters, website and/or social media. Do we have authorization to take/use your child's photo/video in the following ways? Class/School Projects Yes No School Newsletter Yes No Xxxxxxxx Baptist Church/Day School Media Yes No 3rd Child Last Name First Name M.I. Nickname Entering grade Male Female Birth Date Birth City/State Existing medical conditions, medications and/or special attention your child may require Allergies Pediatrician's Name Phone Address Photo/Video: Pictures and/or video may be posted in classrooms, bulletin boards, worship screens, newsletters, website and/or social media. Do we have authorization to take/use your child's photo/video in the following ways? Class/School Projects Yes No School Newsletter Yes No Xxxxxxxx Baptist Church/Day School Media Yes No Additional Comments & Information: Family Registration, continued Parent/Guardian Information Primary Parent (s) 1st Parent/Guardian Last Name First Name M.I. Relationship to Child Email Address ( Individuals) Work Phone Cell Phone Provider Home Resident Street Address Apt: City Zip Code Mailing Address (if different than above: Apt: City Zip Code Occupation Employer Work Address Hours 2nd Parent/Guardian Last Name First Name M.I. Relationship to Child Email Address ( Individuals) Work Phone Cell Phone Provider Home Resident Street Address Apt: City Zip Code Mailing Address (if different than above: Apt: City Zip Code Occupation Employer Work Address Hours Which Guardian Should be Called First? Additional Parent/Guardian Information Non-primary Parent/Guardian Last Name First Name M.I. Relationship to Child Email Address ( Individuals) Work Phone Cell Phone Provider Home Resident Street Address Apt: City Zip Code Mailing Address (if different than above: Apt: City Zip Code Emergency Contact and Authorized Pickups 1st Contact/Pickup Last Name First Name Relationship to Child Home Phone Cell Phone Able to pick up all children in the family Not able to pick up the following children: 2nd Contact/Pickup Last Name First Name Relationship to Child Home Phone Cell Phone Able to pick up all children in the family Not able to pick up the following children: 3rd Contact/Pickup Last Name First Name Relationship to Child Home Phone Cell Phone Able to pick up all children in the family Not able to pick up the following children: Additional Comments and Information that may be helpful Signature Parent/Guardian Signature Date State of California – Health and Human Services Agency California Department of Social Services‌ IDENTIFICATION AND EMERGENCY INFORMATION CHILD CARE CENTERS/FAMILY CHILD CARE HOMES To Be Completed by Parent or Authorized Representative CHILD’S NAME LAST MIDDLE FIRST SEX TELEPHONE ( ) ADDRESS NUMBER STREET CITY STATE ZIP BIRTHDATE PARENT / AUTHORIZED REPRESENTATIVE NAME LAST MIDDLE FIRST BUSINESS TELEPHONE ( ) HOME ADDRESS NUMBER STREET CITY STATE ZIP HOME TELEPHONE ( ) PARENT / AUTHORIZED REPRESENTATIVE NAME LAST MIDDLE FIRST BUSINESS TELEPHONE ( ) HOME ADDRESS NUMBER STREET CITY STATE ZIP HOME TELEPHONE ( ) PERSON RESPONSIBLE FOR CHILD LAST MIDDLE FIRST HOME TELEPHONE ( ) BUSINESS TELEPHONE ( ) ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCY NAME ADDRESS TELEPHONE RELATIONSHIP PHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCY PHYSICIAN ADDRESS MEDICAL PLAN AND NUMBER TELEPHONE ( ) DENTIST ADDRESS MEDICAL PLAN AND NUMBER TELEPHONE ( ) IF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN? CALL EMERGENCY HOSPITAL OTHER EXPLAIN: LIC 700 (10/19) (CONFIDENTIAL) Page 1 of 2 State of California – Health and Human Services Agency California Department of Social Services NAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY (CHILD WILL NOT BE ALLOWED TO LEAVE WITH ANY OTHER PERSON WITHOUT WRITTEN AUTHORIZATION FROM PARENT OR AUTHORIZED REPRESENTATIVE) NAME RELATIONSHIP TIME CHILD WILL BE PICKED UP SIGNATURE OF PARENT/GUARDIAN OR AUTHORIZED REPRESENTATIVE DATE TO BE COMPLETED BY FACILITY DIRECTOR/ADMINISTRATOR/FAMILY CHILD CARE HOMES LICENSEE DATE OF ADMISSION LAST DATE OF ENROLLMENT LIC 700 (10/19) (CONFIDENTIAL) Page 2 of 2 State of California – Health and Human Services Agency California Department of Social Services‌ INDIVIDUAL INFANT SLEEPING PLAN Date of plan: SECTION A: INFANT’S INFORMATION Infant’s Name Gender Birth Date STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CHILD CARE CENTER NOTIFICATION OF PARENTS’ RIGHTS PARENTS’ RIGHTS As a Parent/Authorized Representative’s Name (Primary Contact) Phone Number Authorized Representative’s Name (Secondary Contact) Phone Number, you have the right to:

Discrimination Policy. Xxxxxxxx Day School admits students of any race, color, national and ethnic origin to all the rights, privileges, programs, and activities generally accorded or made available to students at this school. It does not discriminate based on race, color, national and ethnic origin in administration of its educational policies and admissions policies. PARENT(S) SIGNED: Parent/Guardian Date SIGNED: Parent/Guardian Date CENTER SIGNED: Center Representative Date Family Registration Child Information (One per family) 1st Child Last Name First Name M.I. Nickname Entering grade Male Female Birth Date Birth City/State Existing medical conditions, medications and/or special attention your child may require Allergies Pediatrician's Name Phone Address Photo/Video: Pictures and/or video may be posted in classrooms, bullitin boards, worship screens, newsletters, website and/or social media. Do we have authorization to take/use your child's photo/video in the following ways? Class/School Projects Yes No School Newsletter Yes No Xxxxxxxx Baptist Church/Day School Media Yes No 2nd Child Last Name First Name M.I. Nickname Entering grade Male Female Birth Date Birth City/State Existing medical conditions, medications and/or special attention your child may require Allergies Pediatrician's Name Phone Address Photo/Video: Pictures and/or video may be posted in classrooms, bulletin boards, worship screens, newsletters, website and/or social media. Do we have authorization to take/use your child's photo/video in the following ways? Class/School Projects Yes No School Newsletter Yes No Xxxxxxxx Baptist Church/Day School Media Yes No 3rd Child Last Name First Name M.I. Nickname Entering grade Male Female Birth Date Birth City/State Existing medical conditions, medications and/or special attention your child may require Allergies Pediatrician's Name Phone Address Photo/Video: Pictures and/or video may be posted in classrooms, bulletin boards, worship screens, newsletters, website and/or social media. Do we have authorization to take/use your child's photo/video in the following ways? Class/School Projects Yes No School Newsletter Yes No Xxxxxxxx Baptist Church/Day School Media Yes No Additional Comments & Information: Family Registration, continued Parent/Guardian Information Primary Parent (s) 1st Parent/Guardian Last Name First Name M.I. Relationship to Child Email Address ( Individuals) Work Phone Cell Phone Provider Home Resident Street Address Apt: City Zip Code Mailing Address (if different than above: Apt: City Zip Code Occupation Employer Work Address Hours 2nd Parent/Guardian Last Name First Name M.I. Relationship to Child Email Address ( Individuals) Work Phone Cell Phone Provider Home Resident Street Address Apt: City Zip Code Mailing Address (if different than above: Apt: City Zip Code Occupation Employer Work Address Hours Which Guardian Should be Called First? Additional Parent/Guardian Information Non-primary Parent/Guardian Last Name First Name M.I. Relationship to Child Email Address ( Individuals) Work Phone Cell Phone Provider Home Resident Street Address Apt: City Zip Code Mailing Address (if different than above: Apt: City Zip Code Emergency Contact and Authorized Pickups 1st Contact/Pickup Last Name First Name Relationship to Child Home Phone Cell Phone Able to pick up all children in the family Not able to pick up the following children: 2nd Contact/Pickup Last Name First Name Relationship to Child Home Phone Cell Phone Able to pick up all children in the family Not able to pick up the following children: 3rd Contact/Pickup Last Name First Name Relationship to Child Home Phone Cell Phone Able to pick up all children in the family Not able to pick up the following children: Additional Comments and Information that may be helpful Signature Parent/Guardian Signature Date State of California – Health and Human Services Agency California Department of Social Services‌ IDENTIFICATION AND EMERGENCY INFORMATION CHILD CARE CENTERS/FAMILY CHILD CARE HOMES To Be Completed by Parent or Authorized Representative CHILD’S NAME LAST MIDDLE FIRST SEX TELEPHONE ( ) ADDRESS NUMBER STREET CITY STATE ZIP BIRTHDATE PARENT / AUTHORIZED REPRESENTATIVE NAME LAST MIDDLE FIRST BUSINESS TELEPHONE ( ) HOME ADDRESS NUMBER STREET CITY STATE ZIP HOME TELEPHONE ( ) PARENT / AUTHORIZED REPRESENTATIVE NAME LAST MIDDLE FIRST BUSINESS TELEPHONE ( ) HOME ADDRESS NUMBER STREET CITY STATE ZIP HOME TELEPHONE ( ) PERSON RESPONSIBLE FOR CHILD LAST MIDDLE FIRST HOME TELEPHONE ( ) BUSINESS TELEPHONE ( ) ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCY NAME ADDRESS TELEPHONE RELATIONSHIP PHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCY PHYSICIAN ADDRESS MEDICAL PLAN AND NUMBER TELEPHONE ( ) DENTIST ADDRESS MEDICAL PLAN AND NUMBER TELEPHONE ( ) IF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN? CALL EMERGENCY HOSPITAL OTHER EXPLAIN: LIC 700 (10/19) (CONFIDENTIAL) Page 1 of 2 State of California – Health and Human Services Agency California Department of Social Services NAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY (CHILD WILL NOT BE ALLOWED TO LEAVE WITH ANY OTHER PERSON WITHOUT WRITTEN AUTHORIZATION FROM PARENT OR AUTHORIZED REPRESENTATIVE) NAME RELATIONSHIP TIME CHILD WILL BE PICKED UP SIGNATURE OF PARENT/GUARDIAN OR AUTHORIZED REPRESENTATIVE DATE TO BE COMPLETED BY FACILITY DIRECTOR/ADMINISTRATOR/FAMILY CHILD CARE HOMES LICENSEE DATE OF ADMISSION LAST DATE OF ENROLLMENT LIC 700 (10/19) (CONFIDENTIAL) Page 2 of 2 State of California – Health and Human Services Agency California Department of Social Services‌ Services INDIVIDUAL INFANT SLEEPING PLAN Date of plan: SECTION A: INFANT’S INFORMATION Infant’s Name Gender Birth Date Authorized Representative’s Name (Primary Contact) Phone Number Authorized Representative’s Name (Secondary Contact) Phone Number