Hopwood Child Care

Hopwood Child Care

Application for Admission
Basic Information
Child's Name *

First Name Middle Name Last Name
DOB or Expected Due Date *

Month Day Year
Date
Gender *
Male / Female
Child's Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent 1 Name *

First Name Last Name
Parent 1 Phone Number *

Area Code Phone Number
Parent 1 Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Parent 1 Place of Work
Parent 1 E-mail
Parent 2 Name

First Name Last Name
Parent 2 Phone Number

Area Code Phone Number
Parent 2 Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent 2 Place of Work
Parent 2 E-mail
example@example.com
Health Information
Physician's Name
Physician's Phone Number

Area Code Phone Number
Physician's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Special Health Needs
Allergies
*

I understand every effort will be made to reach me in the event of an emergency. If I cannotbe reached I give permission for my Child Care Provider, Hopwood Child Care, to act on my behalf for my child to receive medical care. I authorize and consent to medical, surgical, and hospital care to be preformed for my child by medical staff to safeguard my child’s health. I waive my right of informed consent to such treatment. I also give permission for my child to be transported by ambulance if needed. I certify under penalty of perjury that all information above is true and correct. I understand this application for admission to Hopwood Child Care will not be complete until I have submitted my $50 non-refundable application fee. Once the application fee has been received, my child will then be considered for enrollment and/or placed on the waiting list.
Signature

Clear
Please make checks payable to:

Hopwood Child Care

Mail to:

Hopwood Child Care

103 Hopwood Fairchance Rd

Hopwood, PA 15445
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