APPLICATION FOR CHILD CARE
To be completed and placed on file prior to enrollmentApplication 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)