Application Date
CHILDS APPLICATION FOR CHILD CARE
To be completed and placed on file prior to enrollment
Name of Child
Birth date
(Last) (First) (MI) (Nickname)
Zip Code
INFORMATION ABOUT THE FAMILY
Father/Guardian’s Name
Home Phone
Address
Zip Code
Where Employed
Business Phone
Cell Phone
Preferred Method of Contact Business Cell
Email Address
Home Phone
Address
Zip Code
Where Employed
Business Phone
Cell Phone
Preferred Method of Contact Business Cell
Email Address
Insurance Carrier
Policy #
INFORMATION ABOUT YOUR CHILD:
Does your child have any known allergies:
No Yes
Explain:
Does your child have any chronic
illness/conditions:
No Yes
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:
Name of childs Doctor
Office Phone
Address
Hospital preference
Phone
If neither father nor mother (or guardian) can be contacted, call (please list relationship):
Name
Home Phone
Office Phone
Name
Home Phone
Office Phone
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.
(Signature of Parent)
(Date)
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.
(Signature of Operator)
(Date)
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click to sign
signature
click to edit
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