APPLICATION FOR CHILD CARE

To be completed and placed on file prior to enrollment

Application Date ____________       Date of Enrollment  _________________

INFORMATION ABOUT THE FAMILY:
Name of Child _________________________________ Birth Date _________
                        (Last)       (First)     (MI)  (Nickname)

Father/Guardian's Name______________________Home Phone___________

Address __________________________________________Zip Code ______

Where Employed__________________________Business Phone___________

Mother/Guardian's Name______________________Home Phone___________

Address___________________________________________Zip Code______

Where Employed__________________________Business Phone___________

Insurance Carrier______________________________Policy #____________

INFORMATION ABOUT YOUR CHILD:
Does your child have any known allergies: No_____ Yes ____
Explain:

Please give any information concerning your child which will be helpful in his experience in group setting (such as play, eating and sleeping habits, special fears, special likes of dislikes).______________________________________

_______________________________________________________________

EMERGENCY CARE INFORMATION:
Name of child's doctor_________________________Office Phone__________

Address_________________________________________________________

Name of child's dentist_________________________Office Phone_________

Address_________________________________________________________

Hospital preference_________________________________Phone_________

If neither father nor mother (or guardian) can be contacted, call (please list relationship):

Name____________________Home Phone__________Office Phone________

Name____________________Home Phone__________Office Phone________

If you cannot call for your child, please give the names of persons to whom the child can be released:_________________________________________

_______________________________________________________________

I agree that the operator may authorize the physician of his/her choice to provide emergency care in the event that neither I nor the family physician can be contacted immediately.

_______________________________________________________________
                           (Signature of P:arent)                             (Date)

I, as the operator, do agree to  provide transportation to an appropriate medical resource in the event of an emergency. In an emergency situation, other children in the facility will be supervised by a responsible adult. I will not administer any drug or any medication without specific instructions from the physician or the child's parent, guardian, or full-time custodian. Provisions will be made for adequate and appropriate rest and outdoor play.

________________________________________________________________
                            (Signature of Operator)                           (Date)