Clinton - Cheyenne and Arapaho Child Development Center Application

Cheyenne and Arapaho Child Development Center Application

Clinton Child Development Center
CHILD'S INFORMATION
CHILD'S NAME*

First NameLast Name
AGE*
SEX*

FemaleMale
DATE OF BIRTH*

MonthDayYear
Date
TRIBAL ENROLLMENT (CDIB)
HOME ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
HOME TELEPHONE*

Area CodePhone Number
PARENT OR GUARDIAN INFORMATION
EMAIL
example@example.com
MOTHER'S NAME
MOTHER'S PLACE OF EMPLOYMENT
SOCIAL SECURITY NUMBER
BUSINESS TELEPHONE

Area CodePhone Number
DAY # WHERE MOTHER CAN BE REACHED

Area CodePhone Number
FATHER'S NAME
FATHER'S PLACE OF EMPLOYMENT
SOCIAL SECURITY NUMBER
BUSINESS TELEPHONE

Area CodePhone Number
DAY # WHERE FATHER CAN BE REACHED

Area CodePhone Number
PARENT'S MARITAL STATUS

MARRIEDSINGLEDIVORCEDWIDOWED
IF DIVORCED/SEPARATED, PLEASE INDICATE LEGAL GUARDIAN:
SIBLINGS
NAME
AGE
NAME
AGE
NAME
AGE
NAME
AGE

ENROLLMENT INFORMATION
CHILD CARE TIME SCHEDULE:*

MONDAYTUESDAYWEDNESDAYTHURSDAYFRIDAY
MONDAY ARRIVAL AND DEPARTURE TIME

:HourMinutesAM/PM Option
-
until :HourMinutesAM/PM Option
TUESDAY ARRIVAL AND DEPARTURE TIME

:HourMinutesAM/PM Option
-
until :HourMinutesAM/PM Option
WEDNESDAY ARRIVAL AND DEPARTURE TIME

:HourMinutesAM/PM Option
-
until :HourMinutesAM/PM Option
THURSDAY ARRIVAL AND DEPARTURE TIME

:HourMinutesAM/PM Option
-
until :HourMinutesAM/PM Option
FRIDAY ARRIVAL AND DEPARTURE TIME

:HourMinutesAM/PM Option
-
until :HourMinutesAM/PM Option
ATTENDS SCHOOL?*

YESNO
IF SO, WHERE?
GRADE?
HAS YOUR CHILD BEEN ENROLLED IN A DAY CARE OR PRESCHOOL PROGRAM BEFORE? IF SO, WHERE?
DOES YOUR CHILD HAVE ANY SPECIAL NEEDS OF WHICH WE SHOULD BE AWARE? (SPEECH, HEARING, EMOTIONAL CONCERNS, DIETARY RESTRICTIONS, ALLERGIES, HANDICAPPING CONDITIONS, BREATHING TREATMENTS, ETC.?
CHILD CARE ASSISTANCE
WILL YOU REQUEST CHILD CARE ASSISTANCE FROM?

TRIBESDHS

Cheyenne Arapaho Child Development Program Photographic/Videotaping Permission
The Cheyenne-Arapaho Child Development Program uses photographs, videos, or illustrations of children for may purposes. Such photographs, videos, or other illustrating material may be used in newsletters, on the Tribe’s web page, Tribal newspaper, or in publications produced by the Cheyenne Arapaho Department of Education (DOE), in slide presentations and/or videos about the Program, in video productions aired on television produced by DOE, or in other similar forms of communication.

This form allows you as a parent or guardian to choose whether your child may be in a video, photograph, or other illustration used by the Cheyenne Arapaho Child Development Program.
SELECT ONE:*

I give permission to the Cheyenne Arapaho Child Development Program to make photographs, slides, illustrations, or videos of my child.I do not give permission for my child to be included in presentations by the Cheyenne Arapaho Child Development Program.
Child's Name*
Parent/Guardian*
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date

OSIIS IMMUNICATION SERVICES WEBSITE
The Clinton Child Care Center is required to keep current immunization records on file for all children in care. Jennifer Riggles and Vanessa Hart have approved access to the OIIS Immunization Services Website. This allows for us to access immunizations records for all children in care. This services allows for us to ensure children’s immunizations are up to date. We also have the capabilities of printing off your child’s immunization records. We do not have access to medical records or other personal information.
SELECT ONE:*

I give Concho Child Care Permission to access my child's immunization records through the OIIS portalI do not give Concho Child Care permission to access my child's immunization records through the OIIS portal
Child's Name*
Parent/Guardian Name*
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Cheyenne and Arapaho Child Development Center Application