Child’s Application For Enrollment

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CHILD INFORMATION

Full Name

First

Middle

Last

Child's Physical Address

Address Line 1

Address Line 2

City

State

Zip Code

FAMILY INFORMATION

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Child lives with

Home Phone

Zip Code

Cell Phone

Father/Guardian’s Name

Address (if different from child’s)

Work Phone

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Mother/Guardian’s Name

Address (if different from child’s)

Work Phone

Home Phone

Zip Code (copy)

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.

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Name

Address

Relationship

Phone Numbers

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Name

Address

Relationship

Phone Numbers

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Name

Address

Relationship

Phone Numbers

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
No (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 child has

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

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Name of health care professional

Hospital preference

Office Phone

Phone

I, as the parent/guardian, authorize the center to obtain medical attention for my child in an emergency. Signature of Parent/Guardian.

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.

Child’s Application For Enrollment

CHILD INFORMATION

FAMILY INFORMATION

CONTACTS

HEALTH CARE NEEDS

EMERGENCY MEDICAL CARE INFORMATION

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