CHILDCARE APPLICATION

CHILD'S APPLICATION FOR CHILD CARE

CHILD INFORMATION

Date of Enrollment

First Name

Last Name

NICKNAME

Birth Date

Chil's Physical Address

Child Lives With

FAMILY INFORMATION

Father/Guardian's Name

Home Phone

Address

Zip Code

Place of Employment

Email Address

Business Phone

Cell Phone

Mother/Guardian's Name

Address

Place of Employment

Email Address

Home Phone

Zip Code

Business Phone

Cell Phone

CONTACTS

Full Name

Relationship

Address

Phone Number

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.

Full Name

Relationship

Address

Phone Number

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

Yes

Please attach the medical action plan if your child has one below.

Upload File

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

List any health care needs or concers, symptoms of and type of resonse for these health care needs or concerns.

List any particular fears of 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 CARE INFORMATION

Name of health care professional

Hospital Preference

Office Phone Number

Phone Number

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

Your Signature

Select a date

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.

Date

CMP Administrator (will be added upon form submission)

Thanks for submitting!

CHILD'S APPLICATION FOR CHILD CARE

CHILD INFORMATION

FAMILY INFORMATION

CONTACTS

HEALTH CARE NEEDS

EMERGENCY CARE INFORMATION

To be completed and placed on file prior to enrollment