Child Admission Agreement & Health Assessment Form
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2Child Admission Agreement & Health Assessment
Name of Child
Nickname
Birth Date
Sex
Enrollment Date
month/day/year
(check one)
(check the box if no longer enrolled)
___/____ /_____
F____ M ____
___/____ /_____
___/____ /_____
F____ M ____
___/____ /_____
___/____ /_____
F____ M ____
___/____ /_____
Home Street Address __________________________________________________________
Phone # _____________________
City _______________________________________________________
State ________________
Zip ___________________
Mother’s/Guardian’s Name ____________________________________________________
Phone # _______________________
Employer ______________________________________________________________
Work Phone # ______________________
Father’s/Guardian’s Name _____________________________________________________
Phone # ______________________
Employer ______________________________________________________________
Work Phone # ______________________
Emergency Contacts (Other than Parents) and Persons Authorized to Pick -Up the Child
(Unless there is a court order prohibiting it, parents whose names are not listed can pick up their children.)
Name
Relationship to Child
Address
Phone #
Check if there are no emergency contacts available, other than parents.
Check if there are no persons authorized to pick up the child, other than parents.
Out of Area/State Contact Name
Relationship to Child
Address
Phone #
(If available)
Check if there are no out of area/state contacts available.
In case of emergency or serious illness, when parents cannot be reached immediately, I hereby authorize the provider to obtain
emergency medical care and / or provide emergency medical transportation for my child.
_____________________________________________________________________
______/______/___________
Signature of Parent or Guardian
Date
I hereby give the provider permission to transport my child in the provider’s vehicle for the following (optional):
To and From School
On Field Trips (with written permission in advance)
Other:_____________________________
_____________________________________________________________________
______/______/___________
Signature of Parent or Guardian
Date
(See reverse side for required Health Assessment.)
This form is provided for technical assistance purposes only. Providers may use this form if they choose, but are not required to use this form.
Child Admission Form & Health Assessment
DOH/CCL 12/12
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