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):
    Home Phone:
    Work Phone:
    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? YesNo
    If so, explain:

    Are your Child’s immunizations up to date?YesNo
    If so, explain:

    Authorized Permission
    Field Trips: ALLOWEDNOT allowed
    Non-Vehicle Excursions: ALLOWEDNOT allowed
    Water Activities: ALLOWEDNOT allowed
    Pool Activities: ALLOWEDNOT allowed
    Sprinkler Activities: ALLOWEDNOT allowed

    Child's Health History
    Does child have any known health problems?YesNo
    If so, explain:
    Check any of the following illnesses the child has had:AsthmaEarachesMumpsWhooping CoughBronchitisEczemaPneumoniaPolioChicken PoxFrequent ColdsCroupConvulsionsMeaslesInfluenzaRheumatic FeverDiphtheriaTonsillitis
    Please list any injuries child has had:
    Does your child have any known allergies? YesNo
    If yes, explain what they are and the reactions:
    Does your child take any medication on a regular basis?YesNo
    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? YesNo
    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: