Child Enrollment Form printable pdf download

CHILD ENROLLMENT FORM

Date of Application: _______________ Date of Enrollment: ______________ Last Day of Enrollment:_________

Child’s Name: __________________________________________ Child’s Date of Birth: ____________________

Child’s Address: ________________________________City: __________________________Zip Code:__________

Mother’s Name: ____________________________________ Address:_____________________________________

City: _______________________Zip Code:_________ e-mail address:______________________________________

Home Telephone #: (_____)______________________________ Cell #: (_____)______________________

Mother’s Employer: ______________________________________________ Work #: (____)___________________

Mother’s Employer Address: _______________________ City: __________________________Zip Code:_________

Father’s Name: ________________________________ Address: (if different) ________________________________

City: ________________________Zip Code:_________ e-mail address: ____________________________________

Home Telephone #: (if different)(_____)__________________________ Cell #: (____)_______________________

Father’s Employer: _______________________________________________ Work #: (____)___________________

Father’s Employer Address: ________________________________City: _____________________Zip Code:_______

Weekly Care Schedule: (please include the

Persons to Call in an Emergency or Release Child to

(if

parent(s) can not be reached)

child’s hours in care for each day)

: _______________________________________

Name

Sunday:

__________________________________

: ______________________________________

Address

Monday:

_________________________________

Phone #: _________________ Relationship: _____________________

Tuesday:

_________________________________

Name: ____________________________________________________

Wednesday:

______________________________

Address: _________________________________________________

Thursday:

________________________________

Phone #: _________________Relationship: ______________________

Friday:

__________________________________

Name: ____________________________________________________

Saturday:

________________________________

Address: _________________________________________________

Phone #: _________________Relationship: ______________________

Additional Emergency/Release names:

(Provider’s name)

____________________,

Name: ____________________________________________________

my child care provider, has my permission to transport

Address: __________________________________________________

my child, if necessary, when my child is in care.

Phone #: (____)_______________Relationship: __________________

Physician’s Name: _____________________________

Name: ____________________________________________________

Address: _____________________________________

Address: __________________________________________________

Phone #: (_____)_______________________________

Phone #: (____)________________Relationship: _________________

The provisions outlined on this form have been worked out in consultation with me and have my approval.

Signature of Parent or Guardian __________________________________________________ Date: _____________________

Signature of Parent or Guardian: __________________________________________________ Date: _____________________

Is your child related to the person providing his/her child care?

Yes

No If Yes, what is the

relationship? (Relationship= grandchild, niece, nephew, sibling, son or daughter by blood, adoption or marriage)

(This form must be kept on file for one year after the child is no longer enrolled in the child care home.)

S:DivisionLicensureFamilyField FormsF_ChildEnrollment 11/02/09

(Spanish)

Child Enrollment Form

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