Bureau Of Child Care - Child Enrollment Form
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1
2MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
BUREAU OF CHILD CARE
CHILD ENROLLMENT
SEX
BIRTHDATE
CHILD’S NAME
ADDRESS (STREET, CITY, STATE, ZIP CODE)
HOME TELEPHONE NUMBER
(
)
SCHOOL CHILD ATTENDS
NAME
TELEPHONE NUMBER
(
)
ADDRESS (STREET, CITY, STATE, ZIP CODE)
IDENTIFYING INFORMATION
MOTHER’S OR GUARDIAN’S NAME
HOME TELEPHONE NUMBER
(
)
CELL TELEPHONE NUMBER (OPTIONAL)
ADDRESS __ CHECK HERE IF SAME AS CHILD. (OR LIST STREET, CITY, STATE, ZIP CODE)
(
)
EMPLOYED BY (OR SCHOOL ATTENDED)
HOURS OF EMPLOYMENT
FROM
TO
ADDRESS (STREET, CITY, STATE, ZIP CODE)
BUSINESS TELEPHONE NUMBER
(
)
HOME TELEPHONE NUMBER
FATHER’S OR GUARDIAN’S NAME
(
)
CELL TELEPHONE NUMBER (OPTIONAL)
ADDRESS __ CHECK HERE IF SAME AS CHILD. (OR LIST STREET, CITY, STATE, ZIP CODE)
(
)
EMPLOYED BY (OR SCHOOL ATTENDED)
HOURS OF EMPLOYMENT
FROM
TO
ADDRESS (STREET, CITY, STATE, ZIP CODE)
BUSINESS TELEPHONE NUMBER
(
)
EMERGENCY CONTACT(S)
(ONE REQUIRED)
NAME
TELEPHONE NUMBER
(
)
ADDRESS (STREET, CITY, STATE, ZIP CODE)
RELATIONSHIP
NAME
TELEPHONE NUMBER
(
)
ADDRESS (STREET, CITY, STATE, ZIP CODE)
RELATIONSHIP
PERSONS AUTHORIZED TO TAKE CHILD FROM CHILD CARE FACILITY
(ONE REQUIRED)
NAME
NAME
COMMENTS ON CHILD’S DEVELOPMENT
(NOTE ALLERGIES, HABITS, SPECIAL LANGUAGE, ETC.)
TO BE COMPLETED BY CHILD CARE FACILITY
(FORM TO BE RETAINED FOR ONE YEAR AFTER DISCHARGE)
FACILITY NAME
ADMISSION DATE
ENROLLED FOR (DAYS OF THE WEEK)
FULL TIME / PART TIME
HOURS PER DAY
FROM
TO
DISCHARGE DATE
PLEASE COMPLETE BACK
MO 580-1932 (12-06)
BCC-7
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