Child Care Enrollment Application
Parents, to protect and promote the health and safety of your child, please supply a complete response to every item on this form. This information is required by the Mississippi State Department of Health, and our child care licensure inspector. If the item is not applicable, then please answer "n/a." Do not leave anything blank.
Child's Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mother's Name
First Name
Last Name
Place of Employment
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Father's Name
First Name
Last Name
Place of Employment
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
List any special needs your child may have
I have been informed that this daycare center does not provide liability insurance for my child
Yes
No
I have been given a copy of and have read the MSDH regulation summary for parents
Yes
No
A completed 121 immunization compliance form is on file in the facility before the child attends
Yes
No
IN CASE OF EMERGENCY AND THE PARENTS CANNOT BE REACHED, CONTACT THE FOLLOWING:
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship
THE FOLLOWING PEOPLE ARE AUTHORIZED TO PICK UP AND DROP OFF MY CHILD/CHILDREN
Name
First Name
Last Name
Name
First Name
Last Name
Email
example@example.com
Name
First Name
Last Name
Does your child have any allergies? Please list, including food, if necessary
My child may be photographed at the child care center
Yes
No
My child may take approved field trips sponsored by the child care center
Yes
NO
The childcare center may give my child emergency medical treatment if needed
Yes
No
My child is potty trained
Yes
No
If no, a consultation between the parent and caregiver is required to be documented prior to toilet training. Date of consultation
Parent Signature
Date
-
Month
-
Day
Year
Date
Hours of care needed
Days of care. *Select all that apply
Monday
Tuesday
Wednesday
Thursday
Friday
Meals needed. *Select all that apply
Breakfast
Lunch
Snack
Continue
Continue
Should be Empty: