Online Enrollment Form

Who should use this form?

If you’ve already visited Red Brick Childcare and met with the Administrator and want to enroll, the next step is to complete the Registration Enrollment forms online. You will need to upload or email a few additional completed forms to complete your registration.

Download the zipped folder of all required forms here: Download all enrollment forms

You’ll be able to upload completed forms on this online application OR send them to us via email after you have submitted your online enrollment form.

Step 1 of 4

Basic Enrollment Information
Please enter your name and email so that we can contact you to confirm receipt of this form.
Your Name*
First Last
Your Email Address*
Child's Name*
First Name Last Name
Please enter the name of the child to be enrolled, their birth date, along with the desired start date, days and hours of care. If you have more than one child to enroll, you will be able to enter additional information further down on this page.
Date of Birth*
MM slash DD slash YYYY
Start date of care*
MM slash DD slash YYYY
Please list days and hours of care:*
Example: Monday, 7am - 3pm; Thursday - Friday, 3pm - 7pm
If you have additional children to be enrolled, please list them here:
Format: First and Last Name, Date of Birth, Date of Enrollment, Days and Hours of Care needed.
Referred by

Parent/Guardian Information
Mother / Guardian*
First Name Last Name
Home Phone*
Cell / Other Phone
Email*
Address*
Street Address Address Line 2 City State ZIP Code
Employer*
Occupation*
Work Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
May I use you as a reference?*
- Yes
- No
Father / Guardian*
First Name Last Name
Home Phone*
Cell / Other Phone
Email*
Address*
Street Address Address Line 2 City State ZIP Code
Employer*
Occupation*
Work Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
May I use you as a reference?*
- Yes
- No

Emergency Contact Information
FOR EMERGENCY CONTACT, DISMISSAL AND RELEASE OF MEDICAL INFORMATION, NAMES OF (3) PERSONS, OTHER THAN PARENTS: Red Brick Childcare, LLC. may contact, dismiss and/or release medical information regarding my child(ren) to the persons listed below. I understand that this release shall remain in effect as long as my child remains enrolled. I may terminate or alter this release by completing a new form online or available in office. For my child’s health, safety and welfare, Red Brick Childcare, LLC. may dismiss and/or release medical information to the following:
Emergency Contact 1 - Name*
First Name Last Name
Emergency Contact 1 - Relationship*
Emergency Contact 1 - Phone*
Emergency Contact 2 - Name*
First Name Last Name
Emergency Contact 2 - Relationship*
Emergency Contact 2 - Phone*
Emergency Contact 3 - Name*
First Name Last Name
Emergency Contact 3 - Relationship*
Emergency Contact 3 - Phone*
Medical, Dental, & Allergy Information
Insurance Information
Name of responsible party’s insurance company*
Insurance Contract Number*
Insurance Group Number*
Physician Information
Physician's Name*
Phone*
Clinic Name*
Clinic Address*
Street Address Address Line 2 City State ZIP Code
Please list any and all medications that your child is currently taking:*
Please list all known drug allergies:*
Dentist's Information
Dentist's Name*
Phone*
Clinic Name*
Clinic Address*
Street Address Address Line 2 City State ZIP Code
Does your child have a peanut allergy?*
- Yes
- No
Please list ANY other allergies, special needs or dietary requirements:*

Authorization and Parental Consent
EMERGENCY MEDICAL AUTHORIZATION

IF A PARENT DESIRES NOT TO SIGN THIS CONSENT, THEIR CHILD WILL NOT BE ENROLLED. In the event reasonable attempts to contact me, my spouse or the forgoing persons, have been unsuccessful, I hereby give my consent for the administration of any treatment or medication to my child deemed necessary by my child’s physician/dentist or, in the event the designated practitioner is not available, another licensed physician/dentist, and the transfer of the child to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinion of two licensed physicians concurs in the necessity for such surgery and such concurrence is obtained prior to the performance of such surgery. By enrolling my child as a student in the Red Brick Childcare, LLC program, I authorize the release of my child’s medical information to any emergency personnel and/or person listed herein as an emergency contact and/or person to whom dismissal of my child(ren) is authorized.
ENTER YOUR FULL NAME BELOW. THIS ELECTRONIC SIGNATURE SIGNIFIES AGREEMENT AND CONFIRMS THE AUTHORIZATION.*

Please include "/s/" ahead of your signature.
Photo Permission*
- I give permission for my child’s image to be used by Red Brick Childcare LLC, in its advertising, including but not limited to its website, the newspaper, classroom activity, and the news media. I understand that my child’s name and personal information about my child is never disclosed.
- I do not give permission for my child’s/children’s images to be used for publication.
ENTER YOUR FULL NAME BELOW. THIS ELECTRONIC SIGNATURE SIGNIFIES AGREEMENT AND CONFIRMS THE AUTHORIZATION.*

Please include "/s/" ahead of your signature.
UNDERSTANDING

Once my child is enrolled in the program, I agree to read and abide by the terms, conditions and policies set forth in the Parent Handbook. If I have not received the Parent Handbook two weeks after enrollment I agree to notify the Director. The Director may be contacted by calling the Center. I affirmatively state that I am the custodial parent and have the legal right to enroll my child in the Red Brick Childcare, LLC program.
ENTER YOUR FULL NAME BELOW. THIS ELECTRONIC SIGNATURE SIGNIFIES AGREEMENT AND CONFIRMS THE AUTHORIZATION.*

Please include "/s/" ahead of your signature.
Upload Supplemental Enrollment Forms

We do require that you complete and return the following forms: Download all forms here.

If you have them ready, you can upload them now - OR - complete and drop them off at our location or email them to us at: tinia@redbrickchildcare.com. We'll follow-up with you to make sure your registration is complete.
Upload forms here. Click the button to browse for the file you wish to upload.
Drop files here or

Max. file size: 128 MB.
Any additional comments or questions?
What is your home school district?
May we add you to our mailing list?*
- Yes!
- No, thank you.
Thank you!
Please check your email for a copy of your registration form submission. We will be in touch shortly to request additional forms and information if needed.

Who should use this form?

Step 1 of 4

Basic Enrollment Information

Parent/Guardian Information

Emergency Contact Information

Medical, Dental, & Allergy Information

Insurance Information

Physician Information

Dentist's Information

Authorization and Parental Consent

EMERGENCY MEDICAL AUTHORIZATION

UNDERSTANDING

Upload Supplemental Enrollment Forms

Thank you!