Firefly Child Care Application Form printable pdf download

Firefly Child Application Form

2017-2018 School Year

Child’s Name: ________________________________________________

Date of Birth: __________________

Female _____ Male _____ Nick Name: ___________________________

Start Date: _____________________

ENROLLING:

_____Child Care

_____ Preschool (9-12 only)

_____ Year Round

_____ School Year Only

FAMILY INFORMATION:

Mother’s Name: __________________________________

Father’s Name: _______________________________

Cell # & carrier: __________________________________

Cell # & carrier: ______________________________

Mother’s Occupation: _____________________________

Father’s Occupation: ___________________________

Hours at Work: ___________________________________

Hours at Work: ________________________________

Mother’s Email: _________________________________

Father’s Email: ________________________________

Illnesses, accidents, and surgery child has had (please include childhood diseases and specify allergies):

__________________________________________________________________________________ _______________

__________________________________________________________________________________ ________________

Please explain family structure and dynamics of all people directly influencing your child:

__________________________________________________________________________________________________

Does your child special toy or item/object that they use to comfort themselves? _____ If so, what is it? _______________

Has your child had previous child care experiences? _____ If yes, where? ______________________________________

Does your child have any physical, mental or emotional handicaps? _____ If yes, please describe:

__________________________________________________________________________________________________

Does your child take a nap? _____ If so, when? ______________________________ How long? ___________________

Is your child potty trained or in the process of? _____ If so, what is your process? ________________________________

I give my permission for my child: (Please circle appropriate responses.)

Y or N

To participate in all planned activities at Firefly, including outdoor play and walks. I will be responsible for

providing appropriate clothing.

Y or N

To have my his/her photo taken for newspaper articles or the Firefly website, Facebook and bulletin board.

Firefly Child Care Application Form