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  • Application of Child Information.187161339

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    This document is an application for a child named [NAME] to attend the Learn 'n Grow daycare center located at 2220 Cottonwood Drive in Elgin, IL. It collects contact and medical information about the child and parents, including addresses, phone numbers, doctors, allergies, food preferences, and other details to ensure the proper care of the child. The parents sign acknowledging and agreeing to the information provided on the application.

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    This document is an application for a child named [NAME] to attend the Learn 'n Grow daycare center located at 2220 Cottonwood Drive in Elgin, IL. It collects contact and medical information about the child and parents, including addresses, phone numbers, doctors, allergies, food preferences, and other details to ensure the proper care of the child. The parents sign acknowledging and agreeing to the information provided on the application.

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    24 views2 pages

    Application of Child Information.187161339

    Uploaded by

    Kimberliford19
    This document is an application for a child named [NAME] to attend the Learn 'n Grow daycare center located at 2220 Cottonwood Drive in Elgin, IL. It collects contact and medical information about the child and parents, including addresses, phone numbers, doctors, allergies, food preferences, and other details to ensure the proper care of the child. The parents sign acknowledging and agreeing to the information provided on the application.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as RTF, PDF, TXT or read online from Scribd
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    of 2

    Learn ‘n Grow

    Amy Drexler
    2220 Cottonwood Drive
    Elgin, IL 60123
    Phone 1-224-238-3374
    Website www.learn-n-grow.com
    Email learn_n_grow_qca@yahoo.com

    Application/Record of Child Information

    Name of Child_____________________________ Birth date__________________ Sex_________

    Address_________________________________________________________________________

    Date Child Received_____________________________ Date Child Left______________________

    PARENT INFORMATION:

    Dad Mom
    Name________________________________ Name________________________________
    Home Address_________________________ Home Address_________________________
    _____________________________________ _____________________________________
    Phone Number_________________________ Phone Number_________________________
    Mobile Number_________________________ Mobile Number_________________________
    Place of Employment____________________ Place of Employment____________________
    _____________________________________ _____________________________________
    Work Address__________________________ Work Address__________________________
    _____________________________________ _____________________________________
    Work Phone/Ext._______________________ Work Phone/Ext._______________________
    Working Hours_________________________ Working Hours_________________________

    EMERGENCY CONTACT:
    #1 #2
    Name________________________________ Name________________________________
    Phone Number_________________________ Phone Number_________________________
    Mobile Number_________________________ Mobile Number_________________________
    Relationship___________________________ Relationship___________________________

    PHYSICIAN TO CALL IF CHILD BECOMES ILL OR INJURED:


    Doctor’s Name_________________________ Hospital_______________________________
    Phone Number_________________________ Address______________________________

    Signature’s of Parents:

    Dad’s Signature_______________________ Mom’s Signature_______________________


    If your child has any of the following, please explain:

    Medical problems: _________________________________________________________________

    Physical handicaps: ________________________________________________________________

    Restrictions for play-outdoors: ________________________________________________________

    Restrictions for play-indoors:_________________________________________________________

    Allergies:_________________________________________________________________________

    Food likes: ______________________________________________________________________


    ________________________________________________________________________________

    Food dislikes: ____________________________________________________________________


    ________________________________________________________________________________

    Fears: __________________________________________________________________________

    Does your child take a nap?__________ Time:____________________ Length_____________

    Is your child potty trained?___________ If no, at what age do you plan to start?_______________

    Does your child have special names for objects? (potty, food, drink, etc.)______________________
    ________________________________________________________________________________

    Does your child regularly take medication?__________ If so, what kind & directions?___________
    ________________________________________________________________________________

    If your child is an infant, what are your feeding instructions?_________________________________


    Time:___________________ Amount:____________________ Temperature:______________

    Diaper Changes: Powder?___________ Ointment?__________

    Other information that will help in caring for your child:_____________________________________


    ________________________________________________________________________________
    ________________________________________________________________________________
    ________________________________________________________________________________

    Comments:
    ________________________________________________________________________________
    ALL INFORMATION SHALL BE REGARDED AND HANDLED CONFIDENTIALLY

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