Kiddi Kollege Learning Center Inc. Enrollment Form printable pdf download

Kiddi Kollege Learning Center Inc.

Enrollment Form

Name

___________________________________________________________________________________________________________

Last

First

Middle

Nickname

Address

_________________________________________________________________________________________________________

Age

Date of Birth

Sex

___________________

_______________________________________

___________________________________

Father

Home Address

Phone

___________________

_____________________________________

_____________________________

SS#

Employment

Bus. Address

Bus. Phone

_______________

_____________________

____________

_________________________

Mother

Home Address

Phone

___________________

______________________________________

____________________________

SS#

Employment

Bus. Address

Bus. Phone___________________

_______________

_____________________

_____________

Step Father ________________ Home Address _______________________________________ Phone _____________________________

SS# _______________Employment _______________________ Bus. Address ______________ Bus. Phone_________________________

Step Mother ________________ Home Address ______________________________________ Phone _____________________________

SS# _______________Employment _______________________ Bus. Address _____________ Bus. Phone__________________________

Persons authorized to pick up your child:

Name ________________________ Address ___________________________________Home phone ________________Work phone ____________________

Relative or friend we can contact on an emergency, should parents be unavailable:

Name __________________________________________________ Home phone ________________Work phone ___________________

Child’s doctor _____________________________ Address __________________________________ Phone ________________________

Other children in family ______________ Age _______ Social Security Number________________ afdc ___________________

Food Stamp # ________ Foster child ___________ County you receive assistance from _________ Social worker’s name _______________

Does the child have any special fears and/or problems? ____________________________________________________________________

Does the child have any allergies? ______________ If yes, be specific? _______________________________________________________

Does the child have any history of physical impairments (vision, hearing, speech, etc.)_____________________________________________

Does the child have any information you feel would help Kiddi Kollege to better care for and understand your child? _____________________

LEGAL AUTHORIZATIONS

I hereby give my authorization for Kiddi Kollege Child Care Center to take my child to the below named physician or facility for medical treatment in the event of an

emergency in which neither parent can be reached.

_________________________________________________________________________________________________________________

Doctor

Address

Phone

_________________________________________________________________________________________________________________

Doctor

Address

Phone

I hereby give my authorization to any licensed physician or medical treatment center to treat my child in case of an emergency in which the above named

physician cannot respond.

I hereby give my authorization for Kiddi Kollege Child Care Center to transport my child to and from school, on field trips, or other center sponsored activities.

I hereby represent that I am the legal guardian of the children enrolled and acknowledge that it is my responsibility to keep all information and authorization

pertaining to my child current and up to date.

I hereby acknowledge that my child cannot be admitted to the center until all required forms are completed.

I have authorized the doctor at this time to accept any calls form the center for emergency care.

I hereby acknowledge that I have read and understand the fee arrangements and conditions.

I fully understand the educational program, discipline policies, and parent involvement. Kiddi Kollege Child Care Learning Center is mandated to report suspected

child abuse.

_________________________________________________________________________________________________________________________________

Parent or Legal Guardian Signature

Date

_________________________________________________________________________________________________________________________________

Director Signature

Date