CHILD’S APPLICATION FOR ENROLLMENT

To be completed, signed, and placed on file in the facility on the first day and updated as changes occur and at least annually

Application Date

Date Application Completed

Date of Enrollment

CHILD INFORMATION

Date of Birth

Full Name (Last, First, Middle, Nickname)

Child's Physical Address

FAMILY INFORMATION

Child lives with

Father/Guardian

Name

Home Phone

Address (if different from child’s)

Zip Code

Work Phone

Cell Phone

Mother/Guardian

Name

Home Phone

Address (if different from child’s)

Zip Code

Work Phone

Cell Phone

CONTACTS

Child will be released only to the parents/guardians listed above. The child can also be released to the following individuals. In an emergency, if parents/guardians cannot be reached, the facility may contact:

Name

Relationship

Phone

Name

Relationship

Phone

Name

Relationship

Phone

HEALTH CARE NEEDS

Medical action plan attached?
YesNo

Allergies (symptoms & response)

Health Concerns (symptoms & response)

Behavior / Fears

Medications

Other Important Medical Info

EMERGENCY MEDICAL CARE

Doctor Name

Office Phone

Hospital Preference

Hospital Phone

I, as the parent/guardian, authorize the center to obtain medical attention for my child in an emergency.

Parent/Guardian Signature

Date

I, as the operator, agree to provide transportation to an appropriate medical resource in an emergency.

Administrator Signature

Date

CHILD’S APPLICATION FOR ENROLLMENT

CHILD INFORMATION

FAMILY INFORMATION

Father/Guardian

Mother/Guardian

CONTACTS

HEALTH CARE NEEDS

EMERGENCY MEDICAL CARE

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