Application Forms for Enrollment

Thank you for your interest in becoming a family of our program.

We are excited to get to know you and your family. The application should take about half an hour to complete.

We will review the application and do our selection according to the classroom composition and expected care start time on a first come first served basis.

Once your child is offered the spot. Please confirm the enrollment by submitting the holding deposit, which will apply to the first month of care.
How did you find us?
Please review and complete the licensing forms packet attached below. You may download, fill out and send back to us. OR you may fill out the electronic form below, it will populate all the relevant fields for you.
Child's Name*

First NameMiddle NameLast Name
Child's Birthdate*

MonthDayYear
Birthdate
Sex
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Parent / Authorized Representative 1

Primary Person Responsible for Child
Parent / Authorized Representative 1's Name*

First NameLast Name
Parent / Authorized Representative 1's Phone a*
Please enter a valid phone number.
Parent / Authorized Representative 1's Phone b
Please enter a valid phone number.
Parent / Authorized Representative 1's Email
example@example.com
Parent / Authorized Representative 1's Address*
Parent / Authorized Representative 1's Address
Parent / Authorized Representative 2
Parent / Authorized Representative 2's Name

First NameLast Name
Parent / Authorized Representative 2's Phone Number a
Please enter a valid phone number.
Parent / Authorized Representative 2's Email
example@example.com
Parent / Authorized Representative 2's Address
Parent / Authorized Representative 2's Address
Primary Child Care Needs
My expected start date is*

MonthDayYear
Date
I will need early learning & care program between *

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
I prefer meals option for my child
Describe the relationship you would like to have with your child's early child educator and the community at Modern Education Family Childcare
Does your child have an IEP, 504 plan, or private neuropsychological or pyscho-educational evaluation, and/or does your child currently receive any related service such as OT/PT, speech therapy, special education services or counseling?
Preferred monthly payment method

Emergency Information

This form must be kept for each child in care and identifies whom to call in an emergency. (Other than parents / authorized representatives, you may share up to 4 additional emergency contacts.)
Additional Emergency Contact

Additional persons who may be called in an emergency
Emergency Contact 1's Name

First NameLast Name
Emergency Contact 1's Phone Number
Please enter a valid phone number.
Emergency Contact 1's Relationship to Child
Emergency Contact 1's Address

Add More Emergency Contact
Emergency Contact 2's Name

First NameLast Name
Emergency Contact 2's Phone Number
Please enter a valid phone number.
Emergency Contact 2's Relationship
Emergency Contact 2's Address
Emergency Contact 3's Name

First NameLast Name
Emergency Contact 3's Phone Number
Please enter a valid phone number.
Emergency Contact 3's Relationship
Emergency Contact 3's Address
Emergency Contact 4's Name

First NameLast Name
Emergency Contact 4's Phone Number
Please enter a valid phone number.
Emergency Contact 4's Relationship
Emergency Contact 4's Address

PHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCY
Physician's Name

First NameLast Name
Physician's Address
Physician's Phone
Please enter a valid phone number.
Medical Plan and Number for Physician
Dentist's Name

First NameLast Name
Dentist's Address
Dentist's Phone
Please enter a valid phone number.
Medical Plan and Number for Dentist
IF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN?*

CALL EMERGENCY HOSPITALOther

NAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY
Authorized Pick Up Person 1's Name

First NameLast Name
Authorized Pick Up Person 1's Relationship
Authorized Pick Up Person 2's Name

First NameLast Name
Authorized Pick Up Person 2's Relationship
Authorized Pick Up Person 3's Name

First NameLast Name
Authorized Pick Up Person 3's Relationship
Authorized Pick Up Person 4's Name

First NameLast Name
Authorized Pick Up Person 4's Relationship
Authorized Pick Up Person 5's Name

First NameLast Name
Authorized Pick Up Person 5's Relationship

Individual Infant Sleeping Plan

Must be kept for infants up to 12 months of age. (Skip this if your child is 1 year old and up.)
At home, the infant sleeps in:*

CribPlay YardOther
What are the infant’s usual sleeping hours?*
What is the infant’s average length of the Infant’s nap(s) during the daytime?*

Hour Minutes
Does the infant use a pacifier?*

YesNoSometimes
What is the brand of the pacifier?
My child is able to roll from back to stomach and stomach to back.
My child is able to roll from back to stomach and stomach to back beginning

MonthDayYear
Date
Does the infant have a medical exemption to sleep in a position other than on their back?*

YesNo
Attach medical exemption documents

Cancelof

CONSENT FOR EMERGENCY MEDICAL TREATMENT
AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO
_________________ (FACILITY NAME) TO OBTAIN ALL EMERGENCY MEDICAL OR DENTAL CARE PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR _________________ (CHILD'S NAME). THIS CARE MAY BE GIVEN UNDER WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD NAMED ABOVE.
CHILD HAS THE FOLLOWING MEDICATION ALLERGIES:*
My child has additional medical related consents.*

Nebulizer Care / Inhaled medicationDiabetes / Blood glucose testingNone

NEBULIZER CARE CONSENT/VERIFICATION

(Skip this if your child does not require nebulizer care.)
This form may be used to show compliance with Health and Safety Code Section 1596.798 before a child care licensee or staff person administers inhaled medication to a child in care. A copy of the completed form should be filed in the child’s record and in the personnel file. A separate form must be filled out for each person who administers inhaled medication to the child.

I,_________________(PRINT NAME OF AUTHORIZED REPRESENTATIVE), give my consent for_________________, (PRINT NAME OF LICENSEE OR STAFF PERSON) who work(s) at __________________, (PRINT NAME AND ADDRESS OF CHILD CARE FACILITY) to administer inhaled medication to my child,_________________ (PRINT NAME OF CHILD), and to contact my child’s health care provider.

In addition, I certify that I have personally instructed the above-named licensee or staff person on how to administer inhaled medication to my child.

I have also provided the child care facility with written instructions from my child’s physician, or from a health care provider working under the supervision of my child’s physician (for example, a physician’s assistant, nurse practitioner or registered
nurse). These instructions include:
- Specific indications (such as symptoms) for administering the inhaled medication in accordance with the physician’s prescription.
- Potential side effects and expected response.
- Dose form and amount to be administered in accordance with the physician’s prescription.
- Actions to be taken in the event of side effects or incomplete treatment response in accordance with the physician’s prescription. This includes actions to be taken in an emergency.
- Instructions for proper storage of the medication.
- The telephone number and address of the child’s physician.
NEBULIZER CARE CONSENT*

BLOOD GLUCOSE TESTING CONSENT/VERIFICATION

(Skip this if your child does not require blood glucose testing)
This form may be used to show compliance with Health and Safety Code Section 1596.797 before a child care licensee or staff person performs blood glucose testing on a child in care diagnosed with diabetes. A copy of the completed form should be filed in the child’s record and in the personnel file. A separate form must be filled out for each person who performs blood glucose testing on the child.

I,_________________,(PRINT NAME OF AUTHORIZED REPRESENTATIVE) give my consent for_________________,(PRINT NAME OF LICENSEE OR STAFF PERSON) who work(s) at _________________, (PRINT NAME AND ADDRESS OF CHILD CARE FACILITY) to perform blood glucose testing on my child,_________________, (PRINT NAME OF CHILD) and to contact my child’s health care provider.

In addition, I certify that I have personally instructed the above-named licensee or staff person on how to perform blood glucose testing on my child.

I have also provided the child care facility with written instructions from my child’s physician, or from a health care provider working under the supervision of my child’s physician (for example, a physician’s assistant, nurse practitioner or registered nurse). These instructions include:
- The blood glucose test must be approved by the Federal Food and Drug Administration.
- Specific written directions for performing blood glucose testing in accordance with the physician’s prescription.
- Potential side effects and expected response.
- Actions to be taken in the event of side effects or incomplete treatment response in accordance with the physician’s prescription. This includes actions to be taken in an emergency.
- Instructions for proper storage of the medication.
- The telephone number and address of the child’s physician.
BLOOD GLUCOSE TESTING CONSENT*

I acknowledge I have received and reviewed information below in the complete licensing forms packet:*

Notification of Parents’ Rights (LIC 995A)Caregiver Background Check Process (LIC 995E)Family Child Care Consumer Awareness Information (LIC 9212)Risks and Effects of Lead Poisoning (PUB 515)Parent Notification, Additional Children in Care (LIC 9150)
Signature*

Clear
Signature Date*

MonthDayYear
Date
Should be Empty:

Parent / Authorized Representative 1

Parent / Authorized Representative 2

Primary Child Care Needs

Emergency Information

Additional Emergency Contact

Individual Infant Sleeping Plan

CONSENT FOR EMERGENCY MEDICAL TREATMENT

NEBULIZER CARE CONSENT/VERIFICATION

BLOOD GLUCOSE TESTING CONSENT/VERIFICATION