Fillable ENROLLMENT FORM Parent(s) or Guardians(s)

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ENROLLMENT FORM Parent(s) or Guardians(s)

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File type: PDF

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CASAEARLYLEARNING.COM
ENROLLMENT FORM
Child’s name: _____________________________________________ Date of birth: ___________________
Address: _________________________________________________________________________________
Projected start date: ______________________________________________________________________
Parent(s) or Guardians(s)
Name: __________________________________________________________________________________
Address: ________________________________________________________________________________
Home phone: __________________ Cell phone: __________________Work phone: __________________
Place of work: ______________________________ Occupation: _________________________________
Work address: ___________________________________________________________________________
E-mail address: ___________________________________________________________________________
Name: __________________________________________________________________________________
Address: ________________________________________________________________________________
Home phone: __________________ Cell phone: __________________Work phone: __________________
Place of work: ______________________________ Occupation: _________________________________
Work address: ___________________________________________________________________________
E-mail address: __________________________________________________________________________
Both parents are assumed to be authorized to pick up child unless we have a court order on file specifying otherwise.
Emergency Contacts
Name: ____________________________________________ Phone: _______________________________
Address: ________________________________________________________________________________
Name: ____________________________________________ Phone: _______________________________
Address: ________________________________________________________________________________
CASAEARLYLEARNING.COM
Doctor’s name: ___________________________________ Phone: _________________________________
Address: ________________________________________________________________________________
Dentist’s name: ___________________________________ Phone: _________________________________
Address: ________________________________________________________________________________
Health insurance provider: ________________________________________________________________
Policy holder: _______________________________ Policy number: _______________________________
Child’s days and hours of attendance:
Please provide documentation from your health care provider of any individual child care need or
special condition such as dietary specification, allergies, or asthma.
You must have the Health Care Summary form and Immunization Record completed and signed by
your child’s doctor before admission. Updated exams are required annually, as your child advances
to older age categories.
Child’s name: ______________________________________ Date of birth:___________________________
Parent / Guardian Signature: ___________________________________________ Date: ________________
Director Signature: __________________________________________ Enrollment Date: ________________
MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY
AM
PM
OFFICE USE
V 1st K E/C D/A BD A/P CCM G H/I C MIIC O B DC IF GP
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ENROLLMENT FORM Parent(s) or Guardians(s)

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Completed 12 May 2021

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