CHILDREN'S ENROLLMENT FORM
Child's Name
First Name
Last Name
Sex Age
Date of birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
Format: (000) 000-0000.
Father's Name
First Name
Last Name
Home Phone Number
Format: (000) 000-0000.
Father's Home Address (if different from child's)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Father's Place of Employment
Work Phone
Format: (000) 000-0000.
Father's Employer's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mother's Name
First Name
Last Name
Home Phone Number
Format: (000) 000-0000.
Mother's Home Address (if different from child's)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mother's Place of Employment
Work Phone #
Format: (000) 000-0000.
Mother's Employer's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child's Living Arrangements: (check one)
Both Parents
Mother
Father
Other
Child's Legal Guardian(s): (check one)
Both Parents
Mother
Father
Other
The child may be released to the person(s) signing this agreement or to the following:
Name
*
First Name
Last Name
Address (Street-City-State-Zip)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Telephone Number
Format: (000) 000-0000.
Relationship to child
Relationship to Parent(s) or Guardian
Other identifying information (if any)
Name
*
First Name
Last Name
Address (Street-City-State-Zip)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Telephone Number
Format: (000) 000-0000.
Relationship to child
Relationship to Parent(s) or Guardian
Other identifying information (if any)
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Persons to contact in the case of emergency when parent or guardian cannot be reached:
Name
First Name
Last Name
Telephone Number
Format: (000) 000-0000.
Name
First Name
Last Name
Telephone Number
Format: (000) 000-0000.
Name
First Name
Last Name
Telephone Number
Format: (000) 000-0000.
Name of Public or Private School child attends, if any:
Child's doctor or clinic name
First Name
Last Name
Doctor/clinic phone #
Format: (000) 000-0000.
My child has the following special needs
The following special accommodation(s) may be required to most effectively meet my child's needs while at the center:
My child is currently on medication(s) prescribed for long-term continuous use and/or has the following pre-existing illness, allergies, or health concerns:
EMERGENCY MEDICAL AUTHORIZATION
Should (child's name)
First Name
Last Name
Date of birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
and the facility is unable to contact me (us) immediately, it shall be authorized to secure such medical attention and care for the child as may be necessary. I (We) shall assume responsibility for payment for services.
Parent/Guardian:
First Name
Last Name
Signature
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Parental Agreements with Child Care Facility
The
agrees to provide child care for
First Name
Last Name
on
a.m. to
Hour Minutes
AM
PM
AM/PM Option
p.m. from
Hour Minutes
AM
PM
AM/PM Option
from
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
to
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
My child will participate in the following meal plan (circle applicable meals and snacks):
Breakfast
Morning Snack
Lunch
Afternoon Snack
Evening Snack
Dinner
Bedtime Snack
Before any medication is dispensed to my child, I will provide a written authorization, which includes: date; name of child; name of medication; prescription number; if any; dosages; date and time of day medication is to be given. Medicine will be in the original container with my child's name marked on it.
My child will not be allowed to enter or leave the facility without being escorted by the parent(s), person authorized by parent (s), or facility personnel.
I acknowledge it is my responsibility to keep my child's records current to reflect any significant changes as they occur, e.g., telephone numbers, work location, emergency contacts, child's physician, child's health status, infant feeding plans and immunization records, etc.
The facility agrees to keep me informed of any incidents, including illnesses, injuries, adverse reactions to medications, etc., which include my child.
agrees to obtain written authorization from me before my child participates in routine transportation, field trips, special activities away from the facility, and water-related activities occurring in water that is more than two (2) feet deep.
I authorize the child care facility to obtain emergency medical care for my child when I am not available.
I have received a copy and agree to abide by the policies and procedures for
*
Type: Baby Love Daycare & Childcare Center
I understand that the facility will advise me of my child's progress and issues relating to my child's care as well as any individual practices concerning my child's special needs. I also understand that my participation is encouraged in facility activities.
Signed:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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INFANT FEEDING PLAN
Child's Full Name
First Name
Last Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Does the child take a bottle?
Yes
No
Is the bottle warmed?
Yes
No
Does the child hold own bottle?
Yes
No
Can the child feed self?
Yes
No
Does the child eat: (check all that apply)
Strained Foods
Baby Foods
Formula
Whole Milk
Table Food
Other
What type formula used, if applicable?
Amount and time of formula/breast milk to be given?
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