Enrollment Agreement
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3Enrollment Agreement
Completion of this agreement is required for enrollment. This form will enable us to better understand your child and meet his/her needs. Much of the
information requested is necessary to comply with Pennsylvania's child care licensing regulations.
Admission Date
Enrollment Information
Child’s Information
Child’s first name
Child’s middle name
Child’s last name
Child’s Birthday
Age
Sex
Child’s primary language
Parent/guardian/sponsor primary language
Child’s home address
City
State
Zip
Family Information
Parent/guardian/sponsor
Relationship to child
Primary phone
⃞ This phone is a home phone
⃞ This phone accepts texts
Home address if different from above
Email
Secondary Phone
⃞ This phone is a home phone ⃞ This phone accepts texts
Employer
Work Phone
Employer Address
Parent/guardian/sponsor
Relationship to child
Primary phone
⃞ This phone is a home phone
⃞ This phone accepts texts
Home address if different from above
Email
Secondary Phone
⃞ This phone is a home phone ⃞ This phone accepts texts
Employer
Work Phone
Employer Address
Child Emergency Contact and Release Information (do not include parents/guardians/sponsors)
Please notify the center if an Emergency Release Contact will pick up your child on a given day.
[For the safety of your child, we request that all authorized pick up persons with whom staff is not familiar provide a photo ID at the time of pick up.]
Person # 1
Relationship to child
Primary phone
⃞ This phone is a home phone
⃞ This phone accepts texts
Home address if different from above
City
Zip
Secondary Phone
⃞ This phone is a home phone ⃞ This phone accepts texts
Email
Work Phone
Employer
Person # 2
Relationship to child
Primary phone
⃞ This phone is a home phone
⃞ This phone accepts texts
Home address if different from above
City
Zip
Secondary Phone
⃞ This phone is a home phone ⃞ This phone accepts texts
Email
Work Phone
Employer
Person # 2
Relationship to child
Primary phone
⃞ This phone is a home phone
⃞ This phone accepts texts
Home address if different from above
City
Zip
Secondary Phone
⃞ This phone is a home phone ⃞ This phone accepts texts
Email
Work Phone
Employer
The persons designated in this section will be contacted by us if you cannot be reached in the event of a medical or other emergency. Our staff will only
release your child to you or to those persons listed above. If you want a person who is not identified above to pick up your child, you must notify our staff
in advance, in writing. Your child will not be released without prior authorization.
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