CHILD CARE APPLICATION FOR ENROLLMENT

Emergency Contacts:

Child will be released only to the custodial parent(s) or legal guardian(s) and the persons listed below. The following people will also be contacted and are authorized to remove the child from the facility in case of illness, accident or emergency, if for some reason, the custodial parent(s) or legal guardian(s) cannot be reached:
Name
Address
Work#
Cell/Home#
Name
Address
Work#
Cell/Home#
Name
Address
Work#
Cell/Home#
Name
Address
Work#
Cell/Home#
Helpful Information About Child
- Sections 7.1 and 7.2, of the Child Care Facility Handbook, require a current physical examination (Form 3040) and immunization record (Form 680 or 681) within 30 days of enrollment.
- Section 7.3, of the Child Care Facility Handbook, requires that parents receive a copy of the Child Care Facility Brochure, "Know Your Child Care Facility" (CF/PI 175-24), or
- Section 8.3, of the Family Day Care Home/ Large Family Child Care Home Handbook, requires that parent(s) receive a copy of the family day care home brochure, "Selecting A Family Day Care Home Provider" (CF/PI 175-28
- Section 7.3, C.3 of the Child Care Facility Handbook, requires that parents are provided food and nutrition policies used by the child care facility.
- Section 2.8, of the Child Care Facility Handbook, requires that parents are notified in writing of the disciplinary and expulsion policies used by the child care facility, or
- Section 2.3, of the Family Day Care Home/ Large Family Child Care Home Handbook, requires that parents are notified in writing of the disciplinary and expulsion policies used by the family day care provider.
Your signature below indicates that you have received the above items and that the information on this enrollment form is complete and accurate. I hereby grant permission for the staff of this facility to have access to my child's records.
Signature of Parent/Guardian

Clear
Date

MonthDayYear
Date

Free to Grow Academy: Food Allergies/Food Restrictions
I give permission for my child _____________________ food related activities.
Child's Name
Please check one of the following:

My child DOES NOT have a food allergy or dietary restriction.My child DOES have a food allergy or dietary restriction. He or she may not participate in activitiesMy child DOES have a food allergy or dietary restriction. He or she may participate, but may not eat or handle he following items (please list in next field)
Please list foods that your child may not eat or handle
Photo Authorization

We would like to capture photos of your child(ren) and their daily activities
Choose one of the following options

Yes, I authorize photos of my child(ren) to be taken and published for use by the provider.Yes, I authorize photos of my child(ren), to be taken but only to be shared with me and NOT published in any form.No, I do not authorize photos of my child(ren) to be taken or published in any form.
Parent(s) Signature

Clear
Date

MonthDayYear
Date
During the 2009 legislative session, a new law was passed that requires child care facilities, family day care homes and large family child care homes provide parents with information detailing the causes, symptoms, and transmission of the influenza virus (the flu) every year during August and September.

My signature below verifies receipt of the brochure on Influenza Virus, The Flu, A Guide to Parents
Name
Signature

Clear
Should be Empty:

CHILD CARE APPLICATION FOR ENROLLMENT

Free to Grow Academy: Food Allergies/Food Restrictions

Photo Authorization