1. DAY CARE REGISTRATION (OFFICIAL)

DAY CARE REGISTRATION

One per child
Child's Full Name*
{childsFull}'s Social Security #:*
123456789
I want to :

Register my child for childcare for the first timeJust here to update my pickup list
Does your child have any allergies?*

YesNo
What is your child allergic to?
Children who have special health care needs are those who have chronic physical, developmental, behavioral or emotional conditions expected to last 12 months or more and who also require health and related services of a type beyond that required by children generally. If your child does have special health care needs please discuss these with your child-care provider.
Pediatrician's Name
Telephone Number

Area CodePhone Number
Child's Dentist's Name
Telephone Number

Area CodePhone Number
Name of Family's Medical Facility/Hospital
Telephone Number

Area CodePhone Number
It might be a good idea for you to authorize someone other than yourself to pickup {childsFull}. If you would like us to release {childsFull} to another trusted person, please indicated that person here:

Add a pickup personNo, just me
Contact Name
Relationship
Cell Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Would you like to add another authorize pick-up?

YesNo
Contact Name #2
Relationship
Cell Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Would you like to add another authorize pick-up?

YesNo
Contact Name #3
Relationship
Cell Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Would you like to add another authorize pick-up?

YesNo
Contact Name #4
Relationship
Cell Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Child's Name: {childsFull}
SEX

MaleFemale
DATE OF BIRTH*

MonthDayYear
Date
{childsFull} HOME ADDRESS*
HOME TELEPHONE NUMBER

Area CodePhone Number
MOTHER'S NAME:
MOTHER'S DATE OF BIRTH

MonthDayYear
Date
MOTHER'S SOCIAL SECURITY #:
123456789
MOTHER'S TEL #:
1234567890
FATHER'S SOCIAL SECURITY #:
123456789
FATHER'S TEL #:
1234567890
FATHER'S NAME:
FATHER'S DATE OF BIRTH

MonthDayYear
Date
WHAT IS THE NAME OF THE PERSON APPLYING ON BEHALF OF {childsFull}? *
Your name in most cases
WHAT IS YOUR RELATIONSHIP TO {childsFull}?

ParentGuardianCaretakerRelative
HOME TELEPHONE NUMBER

Area CodePhone Number
DAYTIME TELEPHONE NUMBER

Area CodePhone Number
ADDRESS OF THE PERSON APPLYING FOR THE {childsFull}: (IF DIFFERENT ADDRESS)
AGREEMENTS
I consent to the enrollment of the child listed above in this facility and have been advised of the policies regarding administration of medications, fees, transportation and the services provided by the facility, and the Office of Children and Family Services regulations under which it operates.
I give consent for my child to take part in neighborhood trips (i.e. library, park and playground) away from the facility under proper supervision.*

YesNo
In case of accident or injury, I authorize any and all emergency medical, dental, and /or surgical care and hospitalization advised by the physicians, surgeon or hospital (listed on the other side of this card) necessary for the proper health and well-being of my child.*

YesNo
I have provided information on my child's special needs (Allergies, Diet, Disabilities, and /or Medial Information) to the provider, as may be necessary to assist the facility in properly caring for my child in case of an emergency.*

YesNo
I agree to review and update this information whenever a change occurs and at least once every six months.*

YesNo
SIGNATURE PARENT OR PERSON(S) LEGALLY RESPONSIBLE*

Clear
{whatIs26}'s email address:
Medical Form (attach completed front & back)

Browse Files

Cancelof
DATE

MonthDayYear
Date
And finally, take your best pic of {childsFull}!
Should be Empty:

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DAY CARE REGISTRATION

AGREEMENTS