Todays Date: |
Enrollment Date: |
Child's First Name: |
Child's Middle Name: |
Child's Last Name: |
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Child's Legal Guardian:
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Full Name of Mother:
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Mother's Address:
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Mother's Home Phone:
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Mother's Work Phone:
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Mother's Cell Phone:
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Mother's eMail address:
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Mother's Employer: |
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full name of father: |
Father's address:
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Father's Home Phone:
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Father's Work Phone:
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Father's Cell Phone:
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Father's eMail address:
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Father's Employer:
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Child's Physician:
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Physician's Phone Number: |
Child's Dentist: |
Dentist's Phone Number: |
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Person(s) to contact in case of emergency (other than parent): |
Name:
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Relationship:
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Home Phone:
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Work Phone:
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Name:
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Relationship:
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Home Phone:
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Work Phone: |
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Authorized Pickup |
List Person(s) Authorized to pick up child |
Name:
Phone: |
Name:
Phone:
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Name:
Phone:
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Name:
Phone:
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Name:
Phone:
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Name:
Phone:
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Has child had previous experience away from home?
YesNo
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If so, explain:
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Are your Child’s immunizations up to date?YesNo |
If so, explain: |
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Authorized Permission |
Field Trips: ALLOWEDNOT allowed
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Non-Vehicle Excursions: ALLOWEDNOT allowed
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Water Activities: ALLOWEDNOT allowed
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Pool Activities: ALLOWEDNOT allowed
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Sprinkler Activities:
ALLOWEDNOT allowed
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Child's Health History |
Does child have any known health problems?YesNo
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If so, explain:
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Check any of the following illnesses the child has had:AsthmaEarachesMumpsWhooping CoughBronchitisEczemaPneumoniaPolioChicken PoxFrequent ColdsCroupConvulsionsMeaslesInfluenzaRheumatic FeverDiphtheriaTonsillitis |
Other:
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Please list any injuries child has had:
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Does your child have any known allergies? YesNo
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If yes, explain what they are and the reactions:
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Does your child take any medication on a regular basis?YesNo
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If yes please list the name of the medication(s) and the medical condition for which it is taken:
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Do you have any concerns about your child’s development?
YesNo |
If yes please comment:
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Please comment on any other medical information/ or special need the child care provider should be aware of:
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I authorize the child care provider/staff to obtain the following services for this child if necessary: Public Health Nurse, Physician and or Ambulance in the event of an emergency. (ambulance fees and/or health care costs are the responsibility of the parent/guardian)
Type Your Full Name:
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