Childcare Enrollment Application

Please Note:

Parents, to protect and promote the health and safety of your child, please provide a complete response to every question on this form. This information is required by the Mississippi State Department of Health. If the question does not apply to you, then please enter 'N/A.' Please do not leave anything blank.
Your Child's Full Name

First NameLast Name
Child's Date of Birth:
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guardianship Information

If custody is shared by both parents/guardians, the faculty will abide by the documentation provided on the enrollment application.
Mother/Guardian Name

First NameLast Name
Date of Birth
Drivers License number
Social Security Number
Father/Guardian

First NameLast Name
Drivers License Number
Date of Birth
Social Security Number
Please check which scenario applies, as it relates to guardianship/custody:
Your Phone Number
Format: (000) 000-0000.
Your E-mail Address:
example@example.com
Your Place of Employment:
Work Address:
Work Phone Number:
Please list any special needs your child may have:
Does your child have any allergies? Please list them, including food, if necessary:
Please read the following statements and answer 'yes,' or 'no,'
I have been informed that this Daycare Center does NOT provide liability insurance for my child:
I have been given a copy of and have read the MSDH Regulation Summary for parents:
I have been given and have read and understand the facility's Parent Handbook:
A completed 121 Immunization Compliance Form will be on file in the facility before the child attends:
Initial below that you have read and have answered correctly the statements above.

In the event of an emergency, in which the parents/guardians cannot be reached, please contact:

Rows	Full Name	Relationship	Phone Number	Address
1
2
3
4

The following people are authorized to pick-up and drop-off my child/children. Please list the full names of up to (9) people below.
Complete each of the following sections by checking either, 'yes,' or 'no.'
My child may be photographed at the childcare center:
My child's picture may be used in media, i.e., Facebook, newspaper, etc.:
My child may take approved field trips sponsored by the center:
The center may obtain emergency medical treatment for my child, if needed:
By initialing below, you are stating that you have read and have answered correctly the statements above.
My child is toilet trained:
If no, a consultation between the parent & caregiver is required to be documented prior to toilet training & kept on file. What date are you available for the consultation?

MonthDayYear
Date
My child will eat breakfast/morning snack at the center. If no, my child will eat BEFORE coming into the center:
Parent Signature
Today's Date

MonthDayYear
Date
Director Signature
Today's Date

MonthDayYear
Date
Name

First NameLast Name
Should be Empty:

Please Note:

Please read the following statements and answer 'yes,' or 'no,'

Complete each of the following sections by checking either, 'yes,' or 'no.'