AC Application Form 2025

Child Information
Has your child been enrolled with Bloomingdale Day Care or our Aftercare program Before?
Student Name

First NameLast Name
Start Date

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Grade
School
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medical Information
Primary Doctors Name / Practice
Phone Number
Format: (000) 000-0000.
Does your Child have any Allergies that require special attention
Please list any allergies, medical conditions, including chronic health problems such as asthma seizures behavioral disorders special need etc

Authorized Pick Up Form

Persons authorized to pick up child and/or contact in case of emergency if neither parent is available. They must be within 20-mile radius.
Authorized for Pickup #1
Relationship to Student
Name
Address

Address

Street Address Line 2

CityState

Zip Code
Cellular Phone
Format: (000) 000-0000.
Home Phone
Format: (000) 000-0000.
Email Address
example@example.com
Authorized for Pickup #2
Relationship to Student
Name
Address

Address

Street Address Line 2

CityState

Zip Code
Cellular Phone
Format: (000) 000-0000.
Home Phone
Format: (000) 000-0000.
Email Address
example@example.com
I give Bloomingdale Day Care and After School Program permission to release my child to all individuals listed above, as well as to any additional individuals I may add through the ProCare system or notify the aftercare staff about via the ProCare messaging.
Primary Parent Signature
Primary Parent Name

First NameLast Name
Date

MonthDayYear
Date

Acknowledgement of Receipt of Required
Student Name

First NameLast Name
I/we acknowledge that we have received and reviewed the Parent Handbook for Bloomingdale Day Care After School Program. We understand and agree to all policies and terms outlined therein, including but not limited to the sections listed below.
Expulsion Policy
Initials
Release of Children Policy
Initials
Discipline Policy
Initials
Zero Tolerance Policy
Initials
Personal Electronic Policy
Initials
Social Media Policy
Initials
Financial Policy
Initials
Information about school closings
Initials
Information about providing a snack and drink
Initials
Pick-Up Instructions
Initials
Management of Communicable Diseases Policy
Initials
Medication & Allergy Policy
Initials
Program Permission Form
Initials
Department of Children and Families Office of Licensing Information to Parents Document
Initials
I received the phone numbers for the After School Program and understand that I must call or email if my child will not be at the After School Program on a scheduled day
Initials
Primary Parent Name

First NameLast Name
Primary Parent Signature
Date

MonthDayYear
Date

MEDICAL DECLARATION STATEMENT FOR SCHOOL-AGE CHILD CARE (AND/OR FOR CHILDREN ENROLLED IN PUBLIC OR PRIVATE SCHOOL)
Student Name

First NameLast Name
DATE OF BIRTH

MonthDayYear
Date
Grade
HEALTH STATEMENT (CHECK ONE)
MEDICAL TREATMENT AND INSURANCE RESPONSIBILITY

In the event of illness or injury, Bloomingdale Day Care and After School Program staff will take appropriate action,including administering first aid and contacting emergency medical services if necessary. Parents or guardians willbe notified as soon as possible.Parents/guardians agree to be financially responsible for all medical expenses incurred. Claims should besubmitted to the family’s personal health insurance provider as the primary source of coverage. While Bloomingdale Day Care maintains liability insurance, such coverage is limited and applies only in caseswhere the program is found to be legally responsible. The program and its staff are not financially liable for injuriesthat occur during normal play or routine activities, provided there is no evidence of negligence or misconduct.
Primary Parent
Initials
SCHOOL-AGE CHILD'S SPECIAL CONDITIONS OR NEEDS REQUIRING SPECIAL ACCOMMODATIONS
Please list any allergies medical conditions including chronic health problems such as asthma seizures behavioral disorders special need etc
PARENTGUARDIAN SIGNATURE
DATE

MonthDayYear
Date

EMERGENCY PICKUP FORM
Student Name

First NameLast Name
TODAYS DATE

MonthDayYear
Date
DATE OF BIRTH

MonthDayYear
Date
Grade
School Enrolled In
In the event of an emergency situation or evacuation this form will accompany your child and be the primary source of contact information to connect with parents/guardians
Primary Parent Name

First NameLast Name
Cellular Phone
Format: (000) 000-0000.
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Secondary Parent
Cellular Phone
Format: (000) 000-0000.
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Additional Contact #1
Name
Number
Additional Contact #2
Name
Number
Know AllergiesMedical Conditions
I hereby grant permission for Bloomingdale Day Care to take whatever steps may be necessary in obtaining emergency medical care if warranted.
Signature

Child Information