CHILD’S APPLICATION FOR CHILD CARE
To be completed and placed on file prior to enrollment
(Last) (First) (MI) (Nickname)
INFORMATION ABOUT THE FAMILY
Preferred Method of Contact Business Cell
Preferred Method of Contact Business Cell
INFORMATION ABOUT YOUR CHILD:
Does your child have any known allergies:
Explain:
Does your child have any chronic
illness/conditions:
Please give any information concerning your child which will be helpful in his experience in group setting (such
as play, eating and sleeping habits, special fears, special likes or dislikes).
EMERGENCY CONTACT INFORMATION:
If neither father nor mother (or guardian) can be contacted, call (please list relationship):
If you cannot call for your child, please give the names of persons to whom the child can be released:
I agree that the operator may authorize the physician of his/her choice to provide emergency care in the event
that neither I nor the family physician can be contacted immediately.
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. Provisions will be made for adequate and appropriate rest and
outdoor play.
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