The Nook Registration Form

The Nook Registration Form

The Nook • 5633 S. 16th St., Ste. 100, Lincoln, NE 68512 • (402)413-8849
Please be detailed when completing this registration form. Having the most accurate information when caring for your children helps us ensure you and your child(ren) have the best experience possible!

If you would like to schedule a tour before your registation, please do so here.

Here are a few things to know before your first visit:
- A $45 one time family registration fee is due before your first visit.
- Immunization records or waivers are required within 30 days.
- Children must be 18 months old through 10 years old to attend.
- Children in diapers are welcome!
- Please visit this page to learn more about your first visit and what to expect.
- Find a copy of our Family Handbook here. You will also receive an email with this information once you complete your registration.
At any time during the registration process, if you have questions or concerns please call the center at (402)413-8849 and we'd be happy to assist you.
First, How did you hear about us?*
Who referred you?*
You and your friend each get a free hour for the referral!
Where did you see our ad?*
Which search engine did you use? *
Where did you find us?*

Primary Guardian Information

Hover over a field for more information.
Name*

First NameLast Name
Email*
example@example.com
Primary Phone*
Secondary Phone
Want to stay in the loop? May we text you quick updates about your child’s visits, schedule changes, fun news, and special offers.*

YesNo
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Would you like a family code word? *
A family password is a "code word" that can be used in lieu of showing ID at check out. Only parents/guardians can use the Password, anyone else picking up will be required to show a valid ID.
Family Code Word:*
Please enter the "code word" you'd like to use at checkout to verify your identity. Please do not use your child's name, inappropriate language, or other sensitive information.
Employment Status*
Guardian Employment Information

We are required to collect the following information by the State of Nebraska because we are a licensed child care facility. Please fill out this section throughly. Employment information is used only for emergency situations.
Employer Name*
Workplace Phone Number*
Workplace Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Would you like to enter a secondary guardian?*

YesNo
Secondary Guardian Information

Hover over a field for more information. The secondary guardian is authorized to make changes on the account and pick up unless otherwise specified.
Name*

First NameLast Name
Primary Number*
Please enter a valid phone number.
Secondary Number
Please enter a valid phone number.
Is the secondary guardian authorized for pick up and to make changes to your account at The Nook (if no, please provide appropriate documentation)?*

YesNo
Does the secondary guardian live at the same address as the primary guardian?*

YesNo
Secondary Guardian Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Guardian Employment Status*
Secondary Guardian Employment Information

We are required to collect the following information by the State of Nebraska because we are a licensed child care facility. Please fill out this section throughly. Employment information is used only for emergency situations.
Employer Name*
Workplace Phone Number*
Workplace Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact

At least one emergency contact other than the parents is required by the State of Nebraska.
Please note the following for an Emergency Contact:
- Do not enter yourself or a secondary guardian.
- Please do not use guardian phone numbers.
- A working phone number is required for emergency contacts.
- The emergency contact has permission to pick up your children and make decisions in an emergency.
- An emergency contact is required by the State of Nebraska because we are a licensed child care center. We cannot make exceptions to this requirement.
Emergency Contact*

First NameLast Name
Primary Phone*
Please enter a valid phone number.
Secondary Phone
Please enter a valid phone number.
Relationship to Child*
Enter additional emergency contacts or others authorized for pick up?*

YesNo
Additional Contact
Name*

First NameLast Name
Relationship to Child*
Contact Type*
Phone Number*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Enter additional emergency contacts or others authorized for pick up?*

YesNo
Additional Contact #2
Name*

First NameLast Name
Relationship to Child*
Contact Type*
Phone Number*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Enter additional emergency contacts or others authorized for pick up?*

YesNo
Additional Contact #3
Name*

First NameLast Name
Relationship to Child*
Contact Type*
Phone Number*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Enter additional emergency contacts or others authorized for pick up?*

YesNo
Additional Contact #4
Name*

First NameLast Name
Relationship to Child*
Contact Type*
Phone Number*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
If you have additional contacts, please let us know at your first visit and we can add additional contacts and people authorized for pick up.

Language

Please share with us the language you speak at home.
Is English your child(ren)'s primary language?*

YesNo
How well does your child understand English?*
What is your child(ren)'s native language?*
Anything else you would like us to know about your child's language skills or understanding?

Sunscreen Permission Form

As the parent/guardian of the above child/ren, I recognize that too much exposure to UV rays may be harmful. Therefore, I give permission for the staff at The Nook to apply a sunscreen product that is broad spectrum with SPF 15 or higher, as specified below, when he/she will be playing outside, especially between the months of March through October and between the time of 10am and 4pm.
Please select an option for your child's sun exposure at The Nook:*
Other:*
Please check the box below:*

I understand that sunscreen may be applied to exposed skin, including but not limited to the face (except eyelids), tops of ears, nose, bare shoulders, arms and legs unless otherwise stated above.
Parent/Guardian Initials*

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Medications

Please let us know if your child(ren) takes any medications regularly.
Does/Do any of your child(ren) take medication?*

YesNo

Medication Authorization

Authorization for medications to be administered at The Nook
Please complete the following information with accurate and complete information. Any incomplete information may result in us not being able to administer your child's medication to them while they are in our care. Our policies regarding medications are as follows:
- All medication must be in it's original container
- OTC medications must be in packaging with: medication name, dosage information, and expiration date.
- Prescription medications must be in their original container with a prescription label that includes the child's name, prescribing doctor information, dosage time, amount, and route.
If the medication provided to The Nook does not include all of the required information listed above we cannot give the medication to your child, no exceptions!
Child's Full Name*

First NameLast Name
Medication Name (must match prescription or original bottle)*
Purpose of Medication*
Is medication given a specific time or when symptoms are present?*

Specific TimeSymptoms PresentBothOther
Time of Administration*

Hour Minutes

AM/PM Option
Criteria for administering the medication if given when symptoms are present. *
If other, when should the medication be given?*
Dosage*
Route*
Side Effects to be reported:*
Other notes regarding this medication?
Do you have another medication to enter?*

YesNo

Medication Authorization #2

Authorization for medications to be administered at The Nook
Child's Full Name*

First NameLast Name
Medication Name (must match prescription or original bottle)*
Purpose of Medication*
Is medication given a specific time or when symptoms are present?*

Specific TimeSymptoms PresentBothOther
Time of Administration*

Hour Minutes

AM/PM Option
If other, when should the medication be given?*
Criteria for administering the medication if given when symptoms are present. *
Dosage*
Route*
Side Effects to be reported:*
Other notes regarding this medication?
If you have additional medications to add, please let us know at the center.

Emergency Medical Consent
In the event I cannot be reached to make arrangements, I hereby give my consent to The Nook to my child's doctor.*

YesNo
Doctor's Name*

First NameLast Name
Doctors Phone*
Please enter a valid phone number.
Doctor's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
In case of emergency...*

Take my child to the closest hospitalTake my child to St. Elizabeth's HospitalTake my child to Bryan East HospitalTake my child to Bryan West HospitalOther

Parent/Guardian Signature
I certify that the information provided on this form is accurate and complete to the best of my knowledge. I agree to abide by the policies and procedures of The Nook.
Signature*

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Third Party Payments

Please indicate if you will be utilizing a third party to pay for your care.
Will you be using a child care subsidy (Title XX, Medicaid, etc.) or third party (Bright Horizons, Care.com, etc.)?*

YesNoUnsure

Registration Fee Payment

My Products

Registration FeeOne time family registration fee. Covers all children.

$45.00 Quantity

Enter coupon

Total

$0.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Should be Empty:

The Nook Registration Form

Primary Guardian Information

Guardian Employment Information

Secondary Guardian Information

Secondary Guardian Employment Information

Emergency Contact

Additional Contact

Additional Contact #2

Additional Contact #3

Additional Contact #4

Child Information

Foods Allergies & Preferences

Other allergies

Medical Conditions & Special Needs

Naps & General

Immunizations

Child Information #2

Foods Allergies & Preferences

Other allergies

Medical Conditions & Special Needs

Naps & General

Immunizations

Child Information #3

Foods Allergies & Preferences

Other allergies

Medical Conditions & Special Needs

Naps & General

Immunizations

Child Information #4

Foods Allergies & Preferences

Other allergies

Medical Conditions & Special Needs

Naps & General

Immunizations

Language

Sunscreen Permission Form

Medications

Medication Authorization

Medication Authorization #2

Emergency Medical Consent

Parent/Guardian Signature

Permissions, Release, & Agreements

Health Policy

Parent Rights & Personal Rights

Guardian Acknowledgements

Photo Permission

Third Party Payments

Third Party Payment Acknowlegements

Registration Fee Payment