Child Registration — Zayn Academy

👶 Section 1 — Child Information

First Name *

Middle Name

Last Name *

Date of Birth *

Gender

Desired Start Date

Program *

Home Address

City / State / ZIP

Primary Language Spoken at Home

Ethnicity / Background (optional)

👤 Section 2 — Parent / Guardian 1

First Name *

Last Name *

Relationship to Child

Phone Number *

Email Address *

Employer / Workplace

Work Phone

Work Hours

👤 Section 3 — Parent / Guardian 2 (if applicable)

First Name

Last Name

Relationship to Child

Phone Number

Email Address

Employer / Workplace

🚨 Section 4 — Emergency Contacts

List at least 2 people we can contact in an emergency (other than parents/guardians listed above).

Emergency Contact 1

Full Name *

Relationship

Phone *

Emergency Contact 2

Full Name

Relationship

Phone

🚗 Section 5 — Authorized Pickups

List all individuals authorized to pick up your child. Your child will ONLY be released to these individuals.

Name 1

Relationship

Phone

Name 2

Relationship

Phone

Name 3

Relationship

Phone

🏥 Section 6 — Medical Information

Child's Physician / Doctor

Doctor's Phone

Health Insurance Provider

Policy / Member ID

Known Allergies (food, medication, environmental)

Current Medications (name, dosage, frequency)

Medical Conditions / Special Needs we should know about

Dietary Restrictions

📄 Health Care Summary Required — Minnesota DHS requires a completed Health Care Summary (form MS-2083) signed by your child's healthcare provider before enrollment. Download the form here →

✍️ Section 7 — Consents & Agreements

Emergency Medical Treatment: I authorize Zayn Academy staff to seek emergency medical care for my child if I cannot be reached. *

Photography & Video: I authorize Zayn Academy to take photos/videos of my child for educational and promotional purposes.

Field Trips & Outings: I authorize my child to participate in supervised field trips and off-site activities organized by Zayn Academy.

Sunscreen & Insect Repellent: I authorize staff to apply sunscreen and/or insect repellent to my child during outdoor activities.

Parent Handbook: I have read and agree to the Zayn Academy Parent Handbook and policies. *

CCAP / Subsidized Care: I am applying for or currently receiving Child Care Assistance Program (CCAP) benefits.

Data Privacy: I understand that information provided on this form will be kept confidential and used only for enrollment and childcare purposes as required by MN DHS. *

📝 Section 8 — Additional Notes

Anything else we should know about your child?

How did you hear about Zayn Academy?

Preferred Contact Method

Registration Form

Registration Submitted!