CHILD’S APPLICATION FOR ENROLLMENT

Date ApplicationCompleted:(Required)

Date of Enrollment:(Required)

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

CHILD INFORMATION:

Date of Birth:(Required)

Full Name:(Required)

First Middle Last

Child's Physical Address(Required)

Street Address City State ZIP Code

FAMILY INFORMATION:

Child lives with:(Required)

Father/Guardian’s Name(Required)

Home Phone(Required)

Email Address:

Address (if different from child’s)

Street Address City State ZIP Code

Work Phone

Cell Phone

Mother/Guardian’s Name

Home Phone

Email Address:

Address (if different from child’s)

Street Address City State 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, as authorized by the person who signs this application. In the event of an emergency, if the parents/guardians cannot be reached, the facility has permission to contact the following individuals.

List

Name

Relationship

Address

Phone Number

HEALTH CARE NEEDS:

For any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services, a medical action plan shall be attached to the application. The medical action plan must be completed by the child’s parent or health care professional.

Is there a Medical action plan attached?

Yes

(Medical action plan must be updated on an annual basis and when changes to the plan occur)

List any allergies and the symptoms and type of response required for allergic reactions.

List any health care needs or concerns, symptoms of and type of response for these health care needs or concerns

List any particular fears or unique behavior characteristics the childhas

List any types of medication taken for health care needs

Share any other information that has a direct bearing on assuring safe medical treatment for your child

EMERGENCY MEDICAL CARE INFORMATION:

Name of health care professional

Office Phone

Hospital preference

Phone

Signature of Parent/Guardian(Required)

Date(Required)

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

Signature of Administrator

Date

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CHILD’S APPLICATION FOR ENROLLMENT