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Registration
Child Care Registration
Step
1
of
15
6%
Todays Date:
MM slash DD slash YYYY
Enrollment Date:
MM slash DD slash YYYY
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 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:
Has child had previous experience away from home?
Yes
No
If so, explain:
Are your Child’s immunizations up to date? Yes No
Yes
No
If so, explain:
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
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
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:
Type Your Full Name:
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