Sample Daycare Registration Form (Page 2 of 5) in pdf

The following persons are NOT authorized to pick up my child from the daycare program:

(Please provide copies of any relevant court orders)

Name: ____________________________________________________________________

Address: __________________________________________________________________

Phone number(s): ___________________________________________________________

Name: ____________________________________________________________________

Address: __________________________________________________________________

Phone number(s): ___________________________________________________________

Name: ____________________________________________________________________

Address: __________________________________________________________________

Phone number(s): ___________________________________________________________

HEALTH INFORMATION

1. Are you child’s immunizations up to date? Yes ____ No ____

2. Does your child have any allergies? Yes ____ No _____

If yes, please provide details, including symptoms of the allergic reaction and any treatment.

____________________________________________________________________________

3. Has your child ever had an allergic reaction to a bite or sting? Yes ____ No _____

If yes, please provide details, including symptoms of the allergic reaction. ________________

____________________________________________________________________________

4. Has your child required any special medical care or hospitalization since birth?

Yes ___ No ___

____________________________________________________________________________

5. Does your child receive daily medications? Yes ____ No _____

If yes, please provide details ____________________________________________________

___________________________________________________________________________

Does your child experience any side effects? Yes ____ No _____

If yes, please explain __________________________________________________________

___________________________________________________________________________

6. Has your child had chicken pox? Yes ____ No ______

7. Is your child subject to any of the following (please check any that apply):

___ Asthma

___ Constipation

___ Sore throat

___ Bronchitis

___ Diarrhea

___ Hay fever

___ Colds

___ Ear infections

___ Nose bleeds

___ Other _______________________________________________

__________________________________________________

Shawkwunlee Daycare Registration Form

Sample Daycare Registration Form Page 2