Child Care Enrollment Form

Name of Child: ___________________________________

Birth date: ___/____/___ Sex: M___ F___

Date of Enrollment: _________________________ Age at Enrollment: ___________________________

Parent or Guardian Contact Information
Name (First, Last):

Relationship:

Street Address:

City/State:

Home Phone:

Cell Phone:

Employer/Work Hours:

Work Phone:

Name (First, Last):

Relationship:

Street Address:

City/State:

Home Phone:

Cell Phone:

Employer/Work Hours:

Work Phone:

Zip Code:

Zip Code:

Emergency Contact Information (if parents are unavailable)

Name (First, Last):

Relationship:

Home Phone:

Cell Phone:

Health Insurance Information (in case of emergency)

Insurance Company & Policy Holders Name:

Group #

Physician/Clinics Name:

Office Phone:

ID #

Please list any Likes or Dislikes that your child has:

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Please explain your childs eating habits and schedule:
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Please explain your childs sleeping habits and schedule:
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Has child had previous experience away from home? Yes

No
if yes explain:
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Are your childs immunizations up to date? Yes No

if no please explain:
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Does child have any known health problems? Yes

No
if yes please explain:
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Does you child have any known allergies? Yes

No
if yes please list allergy and reactions:
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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:
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Any other special information provider should be aware of:
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Parent/Guardian Signature: _________________________________________ Date: ___________________
Parent/Guardian Signature: _________________________________________ Date: ___________________