Student Application

ALL DAY LEARNING CENTERS

Focusing on Your Child's Early Education
Date of Application*

MonthDayYear
Date of Birth*

MonthDayYear
Child's Name*
Sex*
Address*
Father's Name*
Mother's Name*
Father's Social Security # (last 4 digits only)
Father's Home Phone
Father's Business Phone
Father's Cell Phone
Father's Email Address*
Father's Occupation
Father's Place of Business
Father's Business Address
Mother's Social Security # (last 4 digits only)
Mother's Home Phone
Mother's Business Phone
Mother's Cell Phone
Mother's Email Address*
Mother's Occupation
Mother's Place of Business
Mother's Business Address
Child's Doctor
Doctor's Phone
Person authorized to pick up child and/or contact in case of Emergency if neither parent is available:
Person 1 - Name
Person 1 - Relationship
Person 1 - Address
Person 1 - Phone
Person 2 - Name
Person 2 - Relationship
Person 2 - Address
Person 2 - Phone
1. Does your child have any known medical conditions? If so, please explain.*
2. Has your child had chicken pox? (choose one)*

YesNo
3. Is your child on any medication? Please describe.*
4. Does your child have any known fears? If so, please explain*
5. Does your child have allergies? If so, please explain*
6. Are there any soups, beverages, or snacks your child is allergic to?*
7. Will your child tell us when he/she has to use the Bathroom? (choose one)*

YesNo
7b. Does your child need help with Bathroom? If so. please explain*
8. Does your child have other sisters or brothers? Their ages?
9. Does your child have a pet or favorite toy?
10. When will you have child arrive at school?*
11. Approximately when we can expect your child to be picked up?*
Thank you for helping the staff at ADLC to know and understand your child better. If there is anything further regarding your child not covered in the form. please let us know. Our policy is to admit students of any race, color, national, or ethic origin.
How did you hear about us?
Parent/Guardian signature*

Clear
Date*

MonthDayYear
Should be Empty:

ALL DAY LEARNING CENTERS

Person authorized to pick up child and/or contact in case of Emergency if neither parent is available: