Childcare Enrollment Application

IDENTIFYING INFORMATION

EMERGENCY CONTACT

EMERGENCY CONTACT AND PERSONS AUTHORIZED TO TAKE CHILD FROM FACILITY OTHER THAN PARENT (AT LEAST ONE EMERGENCY CONTACT IS REQUIRED)

COMMENTS ON CHILD’S DEVELOPMENT

RELATED CHILD

ETHNIC AND RACE INFORMATION

(YOU ARE NOT REQUIRED TO ANSWER THIS SECTION)

CHILD’S PROJECTED ATTENDANCE SCHEDULE AND ANY VARIATIONS EXPECTED

Meals

Holidays

AUTHORIZATION

AUTHORIZATION FOR EMERGENCY MEDICAL CARE

PHYSICIAN OR CLINIC

PREFERRED HOSPITAL

ACKNOWLEDGMENTS