Registration

Child Care Registration Form

Todays Date:
Enrollment Date:
Child's First Name:
Child's Middle Name:
Child's Last Name:

Child's Legal Guardian:

Full Name of Mother:
Mother's Address:
Mother's Home Phone:
Mother's Work Phone:
Mother's Cell Phone:
Mother's eMail address:
Mother's Employer:

full name of father:
Father's address:
Father's Home Phone:
Father's Work Phone:
Father's Cell Phone:
Father's eMail address:
Father's Employer:

Child's Physician:
Physician's Phone Number:
Child's Dentist:
Dentist's Phone Number:

Person(s) to contact in case of emergency (other than parent):
Name:
Relationship:
Home Phone:
Work Phone:
Name:
Relationship:
Home Phone:
Work Phone:

Authorized Pickup

List Person(s) Authorized to pick up child

Name:
Phone:
Name:
Phone:
Name:
Phone:
Name:
Phone:
Name:
Phone:
Name:
Phone:

Has child had previous experience away from home?
 Yes No
If so, explain:

Are your Child’s immunizations up to date? Yes No
If so, explain:

Authorized Permission
Field Trips:  ALLOWED NOT allowed
Non-Vehicle Excursions:  ALLOWED NOT allowed
Water Activities:  ALLOWED NOT allowed
Pool Activities:  ALLOWED NOT allowed
Sprinkler Activities:
 ALLOWED NOT allowed

Child's Health History
Does child have any known health problems? Yes No
If so, explain:
Check any of the following illnesses the child has had: Asthma Earaches Mumps Whooping Cough Bronchitis Eczema Pneumonia Polio Chicken Pox Frequent Colds Croup Convulsions Measles Influenza Rheumatic Fever Diphtheria Tonsillitis
Other:
Please list any injuries child has had:
Does your child have any known allergies?  Yes No
If yes, explain what they are and the reactions:
Does your child take any medication on a regular basis? Yes No
If yes please list the name of the medication(s) and the medical condition for which it is taken:
Do you have any concerns about your child’s development?
 Yes No
If yes please comment:
Please comment on any other medical information/ or special need the child care provider should be aware of:

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: