Childcare Enrollment Application

Childcare Enrollment Application

Prefer paper? You can print this page, fill it out by hand and bring it to Wee Care at 317 Elk Street, Gassaway. No printer? Stop by and we'll give you a paper packet. Questions: 304-364-7077.
Child Information
Child’s Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender

Other
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Desired Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Schedule Needed
Days Needed
Expected Drop-off Time

Hour Minutes

AM/PM Option
Expected Pick-up Time

Hour Minutes

AM/PM Option
Parent/Guardian 1
Full Name

First NameMiddle NameLast Name
Relationship to Child
Phone

Area CodePhone Number
Email
example@example.com
Employer
Work Phone

Area CodePhone Number
Parent/Guardian 2 (Optional)
Full Name

First NameMiddle NameLast Name
Relationship to Child
Phone Number

Area CodePhone Number
Email Address
example@example.com
Employer
Work Phone

Area CodePhone Number
Payment Type
Payment type
Certificate

Cancelof
Emergency Contacts
Emergency Contact 1 Name

First NameMiddle NameLast Name
Emergency Contact 1 Relationship
Emergency Contact 1 Phone

CodePhone Number
Emergency Contact 2 Name

First NameMiddle NameLast Name
Emergency Contact 2 Relationship
Emergency Contact 2 Phone

Area CodePhone Number
Authorized Pick-up People
Note
Pick-up Person 1 Name

First NameMiddle NameLast Name
Pick-up Person 1 Relationship
Pick-up Person 1 Phone

Area CodePhone Number
Pick-up Person 2 Name

First NameMiddle NameLast Name
Pick-up Person 2 Relationship
Pick-up Person 2 Phone

Area CodePhone Number
Pick-up Person 3 Name

First NameMiddle NameLast Name
Pick-up Person 3 Relationship
Health
Child’s Doctor Name
Doctor Phone

Area CodePhone Number
Allergies
Medications
Special Needs or Dietary Requirements
Immunization Record

Cancelof
Physical / Child Health Assessment ECE-CC-3

Cancelof
Permissions
Consent to emergency medical treatment
Permission for field trips
Permission for water activities
Permission to use photos
Required State Forms
West Virginia licensing requires these forms on file before your child's first day. Download, print and fill them out, then upload a photo or scan of each below (or bring them at drop-off).
Child Health Assessment (ECE-CC-3), completed by your child's doctor: https://www.wvdhhr.org/Choices/for-providers/forms/ECE-CC-3%20Child%20Medical.pdf
Emergency Information / Permission Form (ECE-CC-10E): https://www.wvdhhr.org/Choices/for-providers/forms/ECE-CC-10E%20Emergency%20Info%20Form%2011%2008.pdf
Medication Permission Slip (only if your child takes medicine at daycare): https://www.wvdhhr.org/Choices/for-providers/forms/Medical_Permission_Slips.pdf
Using MountainHeart or LINK? Call MountainHeart at 304-872-9200 (https://www.mthtwv.com/mcs/child-care-resource-referral-region-vi/) to apply for childcare assistance.
Upload completed Emergency Information Form (ECE-CC-10E)

Cancelof
Upload Medication Permission Slip (if needed)

Cancelof
Agreement
I have read the Wee Care Parent Handbook and agree to its policies, including the nonrefundable registration fee ($50 MountainHeart / $100 private pay)
E-signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Childcare Enrollment Application

Child Information

Parent/Guardian 1

Parent/Guardian 2 (Optional)

Payment Type

Emergency Contacts

Authorized Pick-up People

Health

Permissions

Required State Forms

Agreement