Children’s Application Leave this field blank 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 Full Name (Last, First, Middle, Nickname): Child's Physical Address: Family Information Child lives with: Father/Guardian's Name Home Phone Father/Guardian's Physical Address If Different From Child Zip Code Work Phone Cell Phone Mother/Guardian's Name Home Phone Mother/Guardian's Physical Address If Different From Child Zip Code Work Phone Cell Phone Contact Child will be release only to the parent/guardians listed above. The child can also be release to the following individuals, as authorized by the person who signs this application. Name (optional) Relationship (optional) Address (optional) Phone Number (optional) Name (optional) Relationship (optional) Address (optional) Phone Number (optional) Name (optional) Relationship (optional) Address (optional) Phone Number (optional) In the event of an emergency, if the parents/guardians cannot be reached, the facility has permission to contact the following individuals. Name (optional) Relationship (optional) Address (optional) Phone Number (optional) Name (optional) Relationship (optional) Address (optional) Phone Number (optional) Health Care Needs: For any child with health care needs such as allergies, asthma, or other chronic condition 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 parents or health care professional. Is there a medical action plan attached? Yes No 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 child has: List any types of medical 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 I, as the parent/guardian, authorize the center to obtain medical attention for my child in an emergency. Signature of Parent/Guardian: Start drawing Clear Done Start over 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 parents, guardian, or full-time custodian. Signature of Administrator (optional) Start drawing Clear Done Start over Date (optional) Submit A place where children grow, learn and thrive. Let's team up together! Inquire Now!
