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Enrollment Application for Child Care
Application Date: 05/19/2012
Name of Child: Last First MI
Nickname(s)
Birth Date:
Address:
Zip Code:

INFORMATION ABOUT THE FAMILY
Father/Guardian's Name: Home Phone:
Address: Zip Code:
Where Employed: Business Phone:
Mother/Guardian's Name: Home Phone:
Address: Zip Code:
Where Employed: Business Phone:
Email:
Other Children in Family: Age: Relation to Child:
Others in Household (Adults or Children): Age: Relation to Child:
Please State reason for seeking child care:
Hours you will need child care services: Arrival:    Departure:

INFORMATION ABOUT YOUR CHILD
Has child had previous group experience? If yes, where?
Has any other person cared for your child regularly? (Grandparents, babysitter):
Does your child take medicine every day? If yes, why?

Any known allergies? To what?

Please specify special instructions, if any, regarding allergies?
Please give any information concerning your child which will be helpful in guiding his/her experiences in group living (such as toileting, eating, sleeping habits, security, fears, likes and dislikes and special needs etc.
If needed, what form of guidance/discipline do you use?

EMERGENCY CARE INFORMATION
Name of Child's Doctor: Office Phone:
Address:
Name of Child's Dentist: Office Phone:
Address:
Hospital Preference: Phone:
In case of an emergency who should be contacted first?
If neither father nor mother (or guardian) can be reached, call (please list relationship)
Name: Home Phone: Office phone:
Name: Home Phone: Office phone:
If you cannot be contacted for your child, please give the names of persons to whom the child can be released. (Names can be added or deleted at any time. Please notify the office)

Electronic Signature

I agree that the operator may authorize the physician of his/her choice to provide emergency care in the event that neither I nor the family physician can be contacted immediately.
Please type your name in the field below and date the form.


(Signature of Parent)
(Date)

I, as the operator do agree to provide transportation to an appropriate medical resource in the event of emergency. In an emergency situation other children in the facility will be supervised by a reasonable adult. I will not administer any drug or any medication without specific instructions from the physician or the child's parent, guardian or full time custodian. Provisions will be made for adequate and appropriate rest and outdoor play.


(Signature of Operator)
(Date)

 

EMERGENCY INFORMATION ON PARENT
Name: Phone:
Address:
Name of Doctor: Phone:
Hospital: Phone:
Name of Dentist: Phone:
To avoid any adverse drug reaction during an emergency, please list medications you are taking:
Allergies:
Blood Type (if known)
List operations / hospitalizations within the Past Year
List chronic medical problems requiring a doctor's care

EMERGENCY CONTACT PERSONS
#1 Name Relationship
Address
Home Phone Business Phone
#2 Name Relationship
Address
Home Phone Business Phone

PARENT HEALTH QUESTIONNAIRE
IMPORTANT: Current health information must be completed by
  1. (1) All Staff (including the director)
  2. (2) All volunteers and Substitutes prior to their coming in contact with children
Name: Last First MI
Home Address:
Telephone Number:

HEALTH STATUS

1) Are you in excellent mental and physical health and are free of communicable disease. Yes No
    (If not, please explain)

2) I take the following medications regularly (please explain)

Electronic Signature

This health statement is accurate to the best of my knowledge. I will advicse the director if my health status changes.

Please type your name in the field below and date the form.


(Signature of Parent)
(Date)