Child Application Form

Date of Enrollment

MonthDayYear
CHILD'S APPLICATION FOR CHILD CARE

To be completed and placed on file prior to enrollment.
CHILD INFORMATION:
Name of Child*

First NameMiddle NameLast NameNickname
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date*

MonthDayYear
Child lives with*

First NameMiddle NameLast Name
FAMILY INFORMATION:
Father/Guardian's Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone*

Area CodePhone Number
Business Phone*

Area CodePhone Number
Cell Phone*

Area CodePhone Number
Where employed*
E-mail*
Mother/Guardian's Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone*

Area CodePhone Number
Business Phone*

Area CodePhone Number
Cell Phone*

Area CodePhone Number
Where employed*
E-mail*
CONTACTS:

Child will be released only to the parents/guardians listed above. The child can also be released to the following individuals, as authorized by the person who signs this application.
Contact's Name*

First NameLast NameRelationship
Phone Number*

Area CodePhone Number
Contact's Name*

First NameLast NameRelationship
Phone Number*

Area CodePhone Number
EMERGENCY CONTACTS:

Child will be released only to the parents/guardians listed above. If we cannot get through to the parents/guardians in the case of an emergency we will contact the following individuals, as authorized by the person who signs this application.
Emergency Contact's Name*

First NameLast NameRelationship
Phone Number*

Area CodePhone Number
Emergency Contact's Name*

First NameLast NameRelationship
Phone Number*

Area CodePhone Number
HEALTH CARE NEEDS:

For any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services, a medical action plan shall be attached to the application. The medical action plan must be completed by the child’s parent or health care professional.
Is there a medical action plan attached?*

YesNo
Medical Action Plan

Upload a File

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List any allergies and the symptoms and type of response required for allergic reactions*

0/100
List any health care needs or concerns, symptoms of and type of response for these health care needs or concerns*

0/100
List any particular fears or unique behavior characteristics the child has*

0/100
List any types of medication taken for health care needs*

0/100
Share any other information that has a direct bearing on assuring safe medical treatment for your child*

0/100
EMERGENCY MEDICAL CARE INFORMATION:
Name of health care professional*
Office Phone*
Hospital Preference*
Phone*
I, as the parent/guardian, authorize the center to obtain medical attention for my child in an emergency.*

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Signature of Parent/Guardian
I, as the operator, do agree to provide transportation to an appropriate medical resource in the event of emergency. In an emergency situation, other children in the facility will be supervised by a responsible adult. I will not administer any drug or any medication without specific instructions from the physician or the child’s parent, guardian, or full-time custodian.

Clear
Signature of Director

CHILD'S APPLICATION FOR CHILD CARE

CHILD INFORMATION:

FAMILY INFORMATION:

CONTACTS:

EMERGENCY CONTACTS:

HEALTH CARE NEEDS:

EMERGENCY MEDICAL CARE INFORMATION: