Enrollment - Quest Zone

Medical Information
Primary Physician's Name*
First Last
Name of Physician's Practice*
Physician's Phone*
Physician's Address*
Street Address Address Line 2 City State ZIP Code
Hospital Preference in Case of Emergency
Allergies or food restrictions?*
- Yes
- No
If yes, please list Allergies or Food Restrictions:
Prescribed medicines?*
- Yes
- No
If yes, please list prescribed medications:
Where are medications dispensed?*
- At Home Only
- At The Quest Zone
- Both
Will your child need assistance or modifications to our programs and/or services to fully participate?*
- Yes
- No
Please Explain Special Needs:*

Scheduling/Attendance

Please indicate your child’s tentative arrival and departure schedule. This information is needed to ensure adequate staff is available to care for your child. This information can be modified, based on your family’s needs.
Scheduling*
Day Hours of Attendance
Permissions
Medical Authorizations*
In the event of an emergency, I give consent for The Quest Zone to secure emergency medical care for my child, including transportation to emergency care. I release The Quest Zone and its employees and agents from liability incurred for any emergency action they perform on behalf of my child.
Field Trips and Special Activities*
I give permission for my child to participate in field trips and special activities offered by The Quest Zone. I understand I will be notified in advance of any activities where my child will be taken off premises, including the date, location, time, etc.. I understand a signed permission slip will be required before my child can attend a trip.
Photographs*
I give permission to The Quest Zone to use still photographs and videos in which my child may appear for the purposes of advertising, employee training, and publicity.
Acknowledgement of Discipline Policy*
I understand The Quest Zone does not allow corporal punishment. Corporal punishment includes spanking, slapping, biting, pinching, jerking or popping hands. These behaviors are not allowed on The Sunshine House premises at any time or by any individual.
How did you hear about us?*
Parent's Signature*
The Quest Zone and The Sunshine House are equal opportunity providers. We accept applications for admission and employment without regard to race, gender, national origin, color, creed, physical or mental disability or any other protected status. Completion of enrollment application does not guarantee enrollment.
Phone
This field is for validation purposes and should be left unchanged.

Name	Relationship to Child	Emergency Contact	Phone 1	Phone 2

Enrollment Form

Step 1 of 4

Day	Hours of Attendance