AC Application Form 2025

Child Information
YesNo
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*
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

Family Information
MotherFatherBothOther
Explain Child Custody
Primary Parent Information
Primary Parent Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary (Cellular Phone)*
Primary (Home Phone)
Primary (Email Address)*
example@example.com
Marital Status
Secondary Parent Information
Secondary Parent Name

First NameLast Name
YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cellular Phone
Home Phone
Email Address
example@example.com
Marital Status
Primary Parent Employer Information
Employer*
Occupation*
Address
City Zip
Work Phone Number*
Secondary Parent Information
Employer
Occupation
Address

Address

Street Address Line 2

City ZipState / Province

Postal / Zip Code
Work Phone Number

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
Home Phone
Email Address
example@example.com
Authorized for Pickup #2
Relationship to Student
Name
Address

Address

Street Address Line 2

CityState

Zip Code
Cellular Phone
Home Phone
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*

Clear
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

Clear
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*
My child is in good health and can participate in the normal activities of the program and has no conditions or special needs that require special accommodations.My child can participate in the normal activities of the program but has conditions or special needs that require special accommodations as indicated below.
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*

Clear
DATE

MonthDayYear
Date

EMERGENCY PICKUP FORM
Student Name*

First NameLast Name
TODAYS DATE

MonthDayYear
Date
DATE OF BIRTH*

MonthDayYear
Date
Grade*
MBD (Martha B. Day)SRD (Samuel R. Donald)WTB (Walter T. Bergen)
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
Home Phone
Work Phone
Secondary Parent
Cellular Phone
Home Phone
Work Phone
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

Clear

Child Information

Medical Information

Family Information

Primary Parent Information

Secondary Parent Information

Primary Parent Employer Information

Secondary Parent Information

Authorized Pick Up Form

Authorized for Pickup #1

Authorized for Pickup #2

Acknowledgement of Receipt of Required

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

SCHOOL-AGE CHILD'S SPECIAL CONDITIONS OR NEEDS REQUIRING SPECIAL ACCOMMODATIONS

EMERGENCY PICKUP FORM

Additional Contact #1

Additional Contact #2

Bloomingdale Daycare LLC.