| 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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