Client Application

Child's Name*

First NameMiddle NameLast Name

Email*

example@example.com

Birth Place*

Date of Birth*

Enrollment Date*

Father*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone Number*

Please enter a valid phone number.

Employer's Name *
Employer's Phone Number   Area Code*   Phone Number*
Employer's Address   Street Address*   Address Line 2*   City*   State*   Zip*
Working Hours * Occupation   *

Mother's Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone Number*

Please enter a valid phone number.

Employer's Name *
Employer's Phone Number   Area Code*   Phone Number*
Employer's Address   Street Address*   Address Line 2*   City*   State*   Zip*
Working Hours * Occupation   *

Marital Status of Parents*

Are you affiliated with a church?*

Name of Church

Siblings *

Name and Age

Is your child left or right handed?*

LeftRightUnknown

Is your child toilet trained?*

YesNo

Does your child use a pacifier*

YesNo

What are some things that soothe our child?*

Does your child have difficulties speaking?*

YesNo

Does your child have any medical problems we need to be aware of?*

Does your child take daily medication?   Yes      No*
What is the medication?   *
Reason for taking medication?   *

Does your child have any kind of allergies? *

If yes, please print the Allergies form and have your child's health care provider provide the requested information. (One can be provided if needed.)

The form below is an authorization of persons who may on a regular basis pick my child/children up at the end of their day.

We will not release you child to anyone without the parent's authorization. The Child Care Ministry must be notified in advance if anyone not listed will be here to pick up your child/children. In case of emergency, you may call the Child Care Ministry, speaking with the person in charge and using the password system that has been established at enrollment to allow an unlisted person to pick-up your child/children. Any person other that the legally responsible parent or guardian will be require dot show photo I.D. before the child/children will be released to them.

The individuals named here have my authorization to pick up   First Name*   Last Name* from St. Paul's Child Care Ministry.
First Name*   Last Name*   Area Code*   Phone Number*
First Name*   Last Name*   Area Code*   Phone Number*
First Name*   Last Name*   Area Code*   Phone Number*
First Name*   Last Name*   Area Code*   Phone Number*

The following individuals are specifically DENIED permission to pick up my child/children due to a court order.
First Name*   Last Name*
First Name*   Last Name*
First Name*   Last Name*
First Name*   Last Name*

Under Indiana law, a child care ministry may choose not to provide certain fire safety protection if the parent(s) or legal guardian(s) of each child is/are notified about the absence of the fire protections. The purpose of this notice is to advise you that this child care ministry does not have the same level of fire safety protection as a licensed child care center. As you have already been notified, the child care ministry does not have to comply with the same sanitation, life and fire safety rules as a licensed child care center. However, I understand that this child care minsitry complies with the State rules concerning sanitaiton and fire safety for the primary use of the structure in which it is conducted. The reason you are being given this notice is that this child care ministry has chosen not ot provide any form of fire warning system, or sprinkler system, as is required for a liensed child care center. This child care ministry is equipped with smoke detectors and fire extinguishers that are checked annually by the State Fire Marshall/Home Land Security.

I/we, the parent(s) or legal guardian(s) of blanks* , acknowledge that I/we have read and understand the above notice concerning fire safety protection.

Signature*

I understand that this chlid care ministry is not licensed under the law of Indiana. However, I understand that this child care minsitry complies with the State rules concerning sanitation and fire safety for the primary use of the structure in which it is conducted. I understand that it is my resposibility to ensure that the nutritional and health needs of my child are met while my child is at the child care minstry.

This notice does not absolve a chlid care ministry from liability for injury to a child while the child is at the child care ministry if the cause of the injury is negligence or intentional wrongdoing on the part of the child care ministry or the employee of the child care ministry.

Signature of Parent or Guardian*

Name of the Child Enrolled*

Child's Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone Number*

Please enter a valid phone number.

Mother's Name*

First NameLast Name

Mother's Cell Phone Number*

Please enter a valid phone number.

Mother's Work Phone Number*

Please enter a valid phone number.

Father' Name*

First NameLast Name

Father's Cell Phone Number*

Please enter a valid phone number.

Father's Work Number*

Please enter a valid phone number.

Family Physician*

Physician's Phone Number*

Please enter a valid phone number.

In the event of an emergency and I cannot be reached please contact:*

Name

Relationship to Child*

Home Phone*

Please enter a valid phone number.

Cell Phone*

Please enter a valid phone number.

Work Phone*

Please enter a valid phone number.

Does your child have allergies?*

YesNo

If yes to what:

Additional Information:

By signing below you certify that hte information on these forms are accurate and complete and gree to th econditions stated herein.

Parent/Guardian Signature:*

Date*

Date

I authorize the staff of St. Paul's Child Care Ministry to take whatever emergency medical measure necessary for the protection of my child while they are in the care of St. Paul's Child Care Ministry. I understand that this includes calling the physician named, implementing his instructions, and transporitng my child to a hospital or clinic without obtaining any further consent.

I agree that St. Paul's Child Ccare Ministry will not be held responsible for any injuries to my child, except injuries that result from acts of negligence or intentional wrongdoing on the part of the Child Care Mininstry staff.

I futher agree, and by my signature give my consent, that in case of accident or illness of a serious nature, my child will be given emergency medical treatment and care, as deemed necessary by emergency personnel that may be contacted through 911. I understand that I will be contacted immediately, or as soon as possible should I be away from the phone numbers listed with my applicaiton for enrollment, but that the first consideration in the event of an emergency will be proper aid for my child. I agree that any expenses incurred by a physician, paramedic, ambulance, or hospital will be the responibility of the child's family.

St. Paul's Child Care Ministry will not be responsible for anything that may happen as a result of false information given at the time of enrollment. St. Paul's Child Care Ministry will not assume responsibility for a child who has not been signed in when he/she arrives for the day.

Mother/Legal Guardian Signature:*

Date*

Date

Father/Legal Guardian Signature:*

Date*

Date

You have indicated that your child has allergies. In an effort to guard the health of your child while in our care, please complete the following questions with your child's health provider and return to us prior to your child's first day of attendance. Be specific with your answers. For example, if your child is allergic to eggs, is he allowed to have foods containing eggs?

A hard copy of this can be provided for you to fill out with your health care provider.

Food Allergies*

Please list

If my child eats this food, the reaction we would expect to see would include (rash, stomach upset, trouble breathing, etc.).

In the event my child is exposed to or ingests the food allergen, the following steps and/or medication should be taken:

Other Allergies:*

Please list all other allergies (medication, insect, air born, etc.)

How should your child be cared for if this allergy should occur while in St. Paul's Child Care Ministry's care?

Parent/Guardians Signature:*

Date*

Date

In the event of a major emergency, such as a fire, gas leak, or other events that would make the building unsafe, the children will be relocated to a safe facility using the church buses. The children will be transported to Travis and Laura Penrod's home (5875 N. 1000 W. Andrews, IN). Located two miles north of the Child Care Ministry. Parents will be notified that they must pick their children up immediately from the Penrod residence. Please complete this form to give us permission to transport your child in this emergency situation.

I, blanks* give permission for St. Paul's Child Care Ministry and County Line Pre-School to transport, Child's Name* by bus to the Penrod residence in the case of an evacuation emergency.

Parent's Signature*

Date*

Date

We love to share with you what your child has done during the day. We do this through our closed class Facebook pages that can only be viewed by parent, who have students in the class and staff. To protect every child and your personal preference of social media, please indicate below if we may post your child's photo or a short video on the closed Facebook page.

May we post your child's picture or video on social media?*

YesNo

Parent's Signature*

Date*

Date

Thank you for enrolling your child in our program! To complete enrollment please make sure you send the one time registration fee of $30.00 along with an updated copy of your child's shot record to St. Paul's Child Care Ministry at 3995 N 1000 W Andrews, IN 46702.

We look forward to serving you and your family!

Client Application

Family Information

Child Information

Authorization for Pick-Up

Notice Concerning Fire Safety Protection

Parent's Notice

Emergency Information

Emergency Medical Authorization

Allergies

Emergency Transportation Form

Photo, Video, & Social Media Release