Family Child Care Enrollment Packet Face Sheet

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*P H O T O OF C H I L D
(*Optional)
FAMILY CHILD CARE
Children’s Records must
P L U S
be maintained for at least
ENROLLMENT PACKET
P H Y S I C A L
five (5) years after a child
D E S C R I P T I O N
has left the program
F A C E
S H E E T
Eye Color _______
Please fill out these forms completely. If a question does not apply
Hair Color ______ Sex_____
to your child, write N/A (not applicable). The forms must be in the
Height _____ Weight _______
educator’s possession on or before the first day your child begins
Other:____________________
care. Please notify your educator if any of the information changes.
_________________________
_________________________
General Information
Date of Admission ________________ Age at Admission: ______
Date of Discharge ______________
Reason for Discharge: _________________________________________________________________
____________________________________________________________________________________
Child's full name ______________________________Date of Birth ______________________________
Address:_______________________________ City:___________________
Zip:________________
Telephone Number: ______________________________ Nickname __________________
Primary Language of Child _____________
Primary Language of Parents_________________
Allergies/Special Diets _________________________________________________________________
Name of Parent(s)/Guardian(s)___________________________________________________________
Home address (if different) ______________________________________________________________
Telephone Number:____________________________________________________________________
Email Address: _______________________________________________________________________
Parent(s)/guardian(s) business address/location during child care:
Parent/Guardian: __________________________
Parent/Guardian ____________________________
Where: __________________________________ Where: ___________________________________
Telephone: _______________________________ Telephone:_________________________________
Cell Phone: _______________________________ Cell Phone:________________________________
Instructions: _______________________________ Instructions:________________________________
_________________________________________ __________________________________________
Emergency Contact/Authorized pick-up person
In the event of an emergency when I may not be reached, the Educator may contact the following
individuals (in the order given) whom I authorize to take my child from the child care premises.
(1) Name: _______________________________ Address _____________________________________
Telephone ______________Cell Phone __________
(2) Name: ______________________________ Address ______________________________________
Telephone _____________ Cell Phone __________
Child’s Name ______________________
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FCCEnrollmentPacket20110406

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