Application Date_____________________________ Date of Enrollment___________________

Name of Child Birth date__________________________________________________________

(Last) (First) (MI) (Nickname) _____________________________________________________

Address Zip Code_______________________________________________________________

INFORMATION ABOUT THE FAMILY:

Father/Guardian’s Name __________________________Home Phone ________________________

Address Zip Code___________________________________________________________________

Where Employed_______________________________ Business Phone______________________

Mother/Guardian’s Name_________________________ Home Phone_________________________

Address ___________________________________________Zip Code _______________________

Where Employed ___________________________Business Phone__________________________

Insurance Carrier Policy # ___________________________________________________________

INFORMATION ABOUT YOUR CHILD:

Does your child have any known allergies: No    Yes   Explain:________________________________

Does your child have any chronic illnesses/conditions: No Yes Explain: ________________________

___________________________________________________________________________________

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 CARE INFORMATION: 
child’s 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)_______________