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CHILD INFORMATION                                                                                                            

FAMILY INFORMATION                                                                                                          


Child will be released only to the parents/guardians listed above. The child can also be released to the following individual(s), 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.

HEALTH CARE NEEDS                                                                                                            

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

Is there a medical action plan attached
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EMERGENCY CARE INFORMATION                                                                                       

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

I, as the operator, do agree to provide transportation to an appropriate medical resource in the event of an emergency. In an emergency situation, other children in the facility will be supervised by a responsible adult. I will not administer any drug of any medication without specific instructions from the physician or the child's parent, guardian, or full-time custodian. 

Thanks for submitting!

To be completed and placed on file prior to enrollment

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