DC - Intake

All God's Children, Inc.

Daycare Intake Packet
Parent/Guardian #1 Information
Parent/Guardian Name*
Phone Number*
Place of Employment
Email Address*
Parent/Guardian #2 Information
Parent/Guardian Name
Phone Number
Place of Employment
Email Address
example@example.com
Child Information
First name*
Last name*
Street address*
City*
Zip code*
Date of Birth*

MonthDayYear
Date
Male or Female?*

FemaleMale
With whom does the child reside?
Is there a custody agreement?
Is this child in the custody of DCBS? If so, please list the child's DCBS worker and county in which the case is currently being managed.
Our family is a(n)...

Emergency Contact and Release of Information
Note that this form grants the individuals listed permission to pick your child up from daycare as well as permission for the AGC Daycare staff to contact the listed individuals in the event of an emergency

If all attempts to reach you, the Guardian, fail in the event of an emergency, list the people you would like us to call in your place. This person should have authorization from you to make necessary medical decisions for your child until you arrive.
Name

First NameLast Name
Relationship to Child
Phone Number

Area CodePhone Number
Name

First NameLast Name
Relationship to Child
Phone Number

Area CodePhone Number
Name

First NameLast Name
Relationship to Child
Phone Number

Area CodePhone Number

Emergency Medical Consent
I hereby consent for the All God’s Children Daycare Staff to administer first aid and/or CPR and obtain necessary medical attention in the event of an emergency for the well-being and/or treatment of
blank*
Hospital Information
Name of Primary Care Doctor
Doctor's Phone Number

Area CodePhone Number
Preferred Hospital Name & Address
Name of Insurance Provider
Insurance Policy Number
Other Information that may be helpful in the event of an emergency:
Signature

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Cultural Assessment
Child's Name

First NameLast Name
Child's Age
What we mean by “culture” are the traditions, ways of living, values, and ideas that are held by a person as a result of their race, language, religion, family, gender, history, economic conditions and disability.
How would you describe your child/family’s ethnic background?

CaucasianHispanic/Latin-AmericanNative AmericanAfrican-AmericanAsian-PacificBi-Racial
Which best describes your family's current home environment?

City (Urban)Country (Rural)Suburban
What is valued or most important in your family?
Are there people, places, things, situations, groups, etc., that your family is opposed or against?
What religious and cultural holidays (if any) does your family celebrate?
Are there any special foods that your family does or does not eat that are a part of your cultural heritage?
What advice can you give to our staff about how to best work with you so that you feel your cultural heritage is respected and supported?

Permission to Photograph
I give permission for my child to have their picture taken at daycare by the staff of the All God’s Children Daycare. I give permission for the pictures taken in daycare to be used on displays in my child’s classroom, on various display boards in the daycare center, to sent via Brightwheel (parent-teacher app) as an update of how the child’s day is going, and as part of craft projects that may be sent home to with my child and/or children in my child’s class.

I recognize that my child has the potential to be in photos that are posted on Facebook or other social media platform by the staff or organization of All God’s Children to share exciting learning experiences that daycare is participating in.
I give permission for my child to be shown in these photos to the extent that I have indicated below

My child MAY NOT be shown in any capacity on social mediaMy child MAY be shown in social media postsMy child MAY be shown in social media posts, with the following conditions: only back of the head or limited profile of the child (no name is ever listed).
Signature

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Permission for Class Pets
On occasion, our older classes may include seasons of maintaining and caring for classroom pets. These pets may be: rabbits, fish, guinea pigs or gerbils.

I give permission for my child to have one of the above-listed animals present in his/her daycare classroom as classroom pets.
Child's Name
Signature

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All God's Children, Inc.