College Admissions Form

CHILDCARE APPLICATION

Enter your admission information below
Child's Name

First NameMiddle InitialLast Name
Birth Date

MonthDayYear
Child's Social Security Number
Format 000-00-0000
Gender

MaleFemale
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PARENTAL INFORMATION
Mother's Name

First NameMiddle InitialLast Name
Mother's Phone Number
Please enter a valid phone number.
Mother's E-mail Address
example@example.com
Father's Name

First NameMiddle InitialLast Name
Father's Phone Number
Please enter a valid phone number.
Father's E-mail Address
example@example.com
Emergency Contact Information
Emergency Contact 1*

First NameLast Name
Emergency Contact 2*

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
Emergency Contact Phone Number*
Please enter a valid phone number.
Emergency Contact Email
example@example.com
Emergency Contact Email
example@example.com
Relationship
Relationship
Medical Information
Primary Care Physician's Name

First NameLast Name
Primary Care Physician's Phone Number
Please enter a valid phone number.
Primary Care Physician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I hereby give my consent to the Director of the Child Care Facility, or his/her duly representative, for said child to receive medical or surgical aid as may be deemed necessary and expedient by a duly licensed or recognized physician or surgeon in case of an emergency when the parents or guardian of said child cannot be reached. Consent is also given for the Director or his/her duly appointed representative to transport said child for emergency medical treatment if the parent or guardian cannot be reached.
I hereby give the Director f the Childcare Facility or his/her appointed representative permission to said child acetaminophen. I understand I will be notified that the medication has been administered.

YesNo
Please list any physical or emotional needs the child may have.
Please include any special medications, formula, diet, allergies, etc.
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Date

MonthDayYear
Date
Should be Empty:

CHILDCARE APPLICATION

PARENTAL INFORMATION

Emergency Contact Information

Medical Information