Sports Club Child Care Enrollment Application Form printable pdf download

Sports CLUB

Child Care Enrollment Application

Student Information: Date of Birth: ___________ Sex: _______ Date of Enrollment: ________________

Full Name: _____________________________________________________School: _______________

Last

First

Middle

Child’s Address: _____________________________________________________________________

Email: _____________________________________________________________________________

Family Information: Drivers License #: ___________________________________________________

Mother's Name: _________________________ Father's Name: ____________________________

Address: ______________________________ Address: _________________________________

Home Phone: __________________________ Home Phone: _____________________________

Employer: _____________________________ Employer: ________________________________

Address: ______________________________ Address: _________________________________

Work Phone: ___________/Cell: ___________ Work Phone: ____________ /Cell:_____________

Custody: Mother ________ Father ________ Both ________ Other ________

Medical Information:

I hereby grant permission for the staff of this facility to contact the following medical personnel to obtain

emergency medical care if warranted:

Doctor: ________________________ Address: ______________________ Phone: _______________

Dentist: ________________________ Address: ______________________ Phone: ______________

Hospital Preference: _________________________________________________________________

Please list allergies, special medical or dietary needs, or other areas of concern: _____________

___________________________________________________________________________________

Contacts: Child will be released only to the custodial parent or legal guardian and the persons listed below.

The following people will also be contacted and are authorized to remove the child from the facility in case of

illness, accident or emergency, if for some reason, the custodial parent or legal guardian cannot be reached:

Name ________________________Address _________________________ Phone# ___________________

I authorize Sports CLUB to apply spray on sunscreen only on my child. (Spray on sunscreen must be

provided by the parent.)

Parent Signature: _____________________________________________ Date: ___________________

Sports Club Child Care Enrollment Application Form