The Oak Tree (South) - Childcare Enrollment Application

Childcare Enrollment Application
Date of Enrollment

MonthDayYear
Date
Facility for Enrollment
Child's Name
Child's Gender
Date of Birth

MonthDayYear
Date
Child's Name
Child's Gender
Date of Birth

MonthDayYear
Date
Child's Name
Child's Gender
Date of Birth

MonthDayYear
Date
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Prior Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Custody:
If court documents are filed in regards to custody, a copy MUST be included with this enrollment application.
Court or Legal Document(s)

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Primary hours of care (Drop off):

Hour Minutes

AM/PM Option
Primary hours of care (Pick up):

Hour Minutes

AM/PM Option
Funding:
Do you currently have a child or children attending the childcare facility?
If so child(ren)'s name.
Has the child or children attended any of our facilities in the last 2 years?
If so which facilities
Is your child or children currently enrolled at another facility?
If so, name of facility
Has your child or children ever been suspended or expelled from any childcare facility?
If so, please explain.
Parent/Guardian
Email Address
example@example.com
Cellphone
Format: (000) 000-0000.
Home Address
Employer
Work Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to child
Parent/Guardian
Email Address
example@example.com
Cellphone
Format: (000) 000-0000.
Home Address
Employer
Work Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to child
I/We hereby grant permission for the staff of this facility to contact the following medical personnel to obtain emergency medical care if warranted. I also agree to old harmless and release The Oak Tree Christian Academy, its affiliates and its emplyees from all liabilities. I further, agree to keep the facility informed of changes in telephone numbeers where I can reached.
Pediatrician
Phone
Format: (000) 000-0000.
Dentist
Phone
Format: (000) 000-0000.
Hospital Preference
Does your child require an Emergency Care Plan due to an allergy, medical diagnosis, or an increased risk for a chronic physical, developmental, behavioral, emotional condition or additional services?
If so, please fill out the appropriate Emergency Care Plan.
Is your child currently receiving therapy or some other assistance/service due to physical, developmental, behavioral, or emotional condition or delay?
If so, please describe below and provide documentation (encourage).
File Upload

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Please list allergies, special medical or dietary needs, or other areas of concern:
EMERGENCY CONTACTS
Name
Relationship to children
Contact
Name
Relationship to children
Contact
Name
Relationship to children
Contact
Enrollment Information
Acknowledgments
do 1 do not I/We _____ or ______ grant permission for my child(ren)'s photo to be taken and used for promotional purposes including, but not limited to brochures, advertisements, and social media. I understand that If I do not grant permission, my child(ren)'s photo will still be taken for classroom use.
File Upload: Current Shot Record and Signed Physical Form

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Your signature below indicates that you have received the above items and that the information on The Enrollment Application is complete and accurate. Your signature also indicates that you have received, read, and agree to the terms set forth in the Parent Handbook.
Signature of ParentGuardian
Date

MonthDayYear
Date
Signature of ParentGuardian
Date

MonthDayYear
Date
Should be Empty:

Childcare Enrollment Application

EMERGENCY CONTACTS