BRIGHT MORNING STAR CHILD CARE APPLICATION FORM

Child Admission Agreement
Name of Child*

First NameMiddle NameLast Name
Nickname
Child's Birthdate*

MonthDayYear
Date
Child's Sex
Child's Sex

FemaleMale
Date of Enrollment (For management to enter, unless start date is known.)

MonthDayYear
Date
(For administrative use.)

Check if no longer enrolled.
Home Street Address*
City*
State*
Zip*
Home Phone #*
Parent's/Guardian's Name #1*
Parent's/Guardian's Cell Number #1*

Area CodePhone Number
Parent's/Guardian's Work Number #1

Area CodePhone Number
Parent's/Guardian's Work Phone #1
Parent's/Guardian's Email #1*
example@example.com
Parent's/Guardian's Name #2
Parent's/Guardian's Cell Number #2

Area CodePhone Number
Parent's/Guardian's Work Phone #2

Area CodePhone Number
Parent's/Guardian's Work Phone #2
example@example.com
Parent's/Guardian's Work Phone #
Parent's/Guardian's Email #2
example@example.com
EMERGENCY CONTACTS AND PERSONS AUTHORIZED TO PICK UP CHILD (other than parents) Unless there is a court order prohibiting it, parents whose names are not listed can pick up their children.*

There are NO EMERGENCY CONTACTS available, other than parents.There are NO persons AUTHORIZED TO PICK UP this child, other than parents.Emergency contacts and/or persons authorized to pick up this child are listed below.
Name of Emergency Contact #1

First NameLast Name
Relationship to Child of Emergency Contact #1
Address of Emergency Contact #1
Phone Number of Emergency Contact #1

Area CodePhone Number
Name of Emergency Contact #2

First NameLast Name
Relationship to Child of Emergency Contact #2
Address of Emergency Contact #2
Phone Number of Emergency Contact #2

Area CodePhone Number
Name of an Out-Of-Area Contact (if applicable)
Check if there are no out-of-area contacts.
Relationship to Child of Out-Of-Area Contact
Address of Out-Of-Area Contact
Phone Number of Out-Of-Area Contact

Area CodePhone Number
In case of an emergency or a serious illness and the parents cannot be reached immediately, I hereby authorize the provider to obtain emergency medical care and/or provide emergency medical transportation for my child.
Name of Parent/Guardian
Signature*

Clear
Date*

MonthDayYear
Date
I hereby give the provider permission to transport my child in the provider’s vehicle for the following (optional):

To and From SchoolOn Field Trips (with written permission in advance)Other
Name of Parent/Guardian
Signature

Clear
Date

MonthDayYear
Date
The parent/guardian must review this form annually and note any changes.

(Leave these dates and signatures blank if this is a new application.)
Date of 1st Annual Renewal (skip if new application)

MonthDayYear
Date
Name

First NameLast Name
Parent Signature After 1st Annual Renewal (skip if new application)

Clear
Date of 2nd Annual Renewal (skip if new application)

MonthDayYear
Date
Name

First NameLast Name
Parent Signature After 2nd Annual Renewal (skip if new application)

Clear
Date of 3rd Annual Renewal (skip if new application)

MonthDayYear
Date
Parent Signature After 3rd Annual Renewal (skip if new application)

Clear
Child Health Assessment
Name of Child*
Birth Date*

MonthDayYear
Date
DOES YOUR CHILD HAVE ANY KNOWN ALLERGIES OR SENSITIVITIES TO:
MEDICATIONS*

NoYes
If yes, please list:
FOODS*

NoYes
If yes, please list:
OTHER*

NoYes
If yes, please list:
Are any listed allergies life-threatening?

NoYes
If yes, please indicate which one and provide important details.
CHECK ALL THAT APPLY TO YOUR CHILD'S MEDICAL CONDITION:*

AsthmaDiabetesSeizuresHeart problemsHearing impairmentVisual impairmentDevelopment delaysPhysical impairmentBehavioral or emotional problemsTo my knowledge, my child does NOT experience any of the above issues.
List any other applicable illnesses or medical conditions not listed above:
Explain any additional health information or special instructions you feel we need to be aware of:
List any regular medications your child takes OR mark as N/A:*
Name of Child's Medical Provider:*
Parent/Guardian Name
Signature*

Clear
Date*

MonthDayYear
Date
This form must be completed for each individual child enrolled, and the parent/guardian must review it annually and note any changes. (Leave these dates and signatures blank if this is a new application.)
Date of 1st Annual Renewal (skip if new application)

MonthDayYear
Date
Parent/Guardian Name

First NameLast Name
Parent Signature After 1st Annual Renewal (skip if new application)

Clear
Date of 2nd Annual Renewal (skip if new application)

MonthDayYear
Date
Parent/Guardian Name

First NameLast Name
Parent Signature After 2nd Annual Renewal (skip if new application)

Clear
Date of 3rd Annual Renewal (skip if new application)

MonthDayYear
Date
Parent Signature After 3rd Annual Renewal (skip if new application)

Clear
Family Needs Assessment
This section will help us match your child to the best spot at one of our locations.

While we specialize in working with parents' schedules, we cannot accommodate everybody. Decisions are made on a case-by-case basis, according to current openings and schedules of other enrollees. We are NOT a 24-hour facility.

If we don't have a current opening that meets your needs, we may give you the option of being added to a waiting list.
Name of Child*

First NameLast Name
Age of Child*
Name of Child's School*
ARE YOU ALSO APPLYING TO ENROLL OR HAVE ALREADY ENROLLED ANY OF THEIR SIBLINGS? PLEASE LIST:
Name of 1st Sibling Already Enrolled or to be Enrolled:

First NameLast Name
Age of 1st Sibling:
Name of School 1st Sibling Attends:
Name of 2nd Sibling Already Enrolled or to be Enrolled:

First NameLast Name
Age of 2nd Sibling:
Name of school 2nd Sibling Attends:
Name of 3rd Sibling Already Enrolled or to be Enrolled:

First NameLast Name
Age of 3rd Sibling:
Name of school 3rd Sibling Attends:
Name of 4th Sibling Already Enrolled or to be Enrolled:

First NameLast Name
Age of 4th Sibling:
Name of school 4th Sibling Attends:
SCHEDULE NEEDS
How often do you need childcare?*

More than 5 days per week5 days per week4 days per week3 days per weekTwice per weekOne day per week3-5 days, every other weekA few days per monthOther
Which days of the week? (You can choose more than one.)*

MondaysTuesdaysWednesdaysThursdaysFridaysSaturdaysSundays (not currently offered ant any of our locations)Rotates
If your schedule rotates, list the days you rotate through:
How many hours per day do you typically need?*

1-2 hours2-3 hours3-4 hours4-5 hours5-6 hours6-7 hours7-8 hours8+ hours
What time of day do you typically need childcare? (Can choose more than one.)*

Early mornings (starting before 8 AM)Standard business hours (within 8 AM - 6 PM)Extended evening hours (after 6 PM)Other
Is there any further information you would like us to know about your schedule?
For which activities do you typically need childcare? (Can choose more than one.)*

Full-time jobRegular part-time jobCall-in job / per diemAppointmentsErrandsRespite / breaksOther
SPECIAL CARE NEEDS
Which best describes this child's diapering/potty needs?*

In diapersStarting to potty-trainMostly potty-trainedCompletely potty trained when awake100% potty-trainedOther
Mark any special needs. (We will reference the above application for the details.)

Mild allergies / food intollerancesLife-threatening allergiesDevelopmental delaysPhysical impairmentBehavioral or emotional problemsOther relevant health or medical issues
Do you have any transportation needs?
Should be Empty:

Child Admission Agreement

Child Health Assessment

Family Needs Assessment