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Enrollment Form

This document is a child care enrollment form requesting information about a child enrolling in care. It collects the child's name, birthdate, sex, and enrollment dates. Contact information is requested for the child's parents or guardians, including names, addresses, phone numbers and employers. Emergency contact information and health insurance details are also provided in case of emergency. The form asks about the child's likes/dislikes, eating/sleeping habits, medical history including immunizations and allergies, and any medications taken regularly. Parents sign to acknowledge the information.

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lyssat83
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129 views2 pages

Enrollment Form

This document is a child care enrollment form requesting information about a child enrolling in care. It collects the child's name, birthdate, sex, and enrollment dates. Contact information is requested for the child's parents or guardians, including names, addresses, phone numbers and employers. Emergency contact information and health insurance details are also provided in case of emergency. The form asks about the child's likes/dislikes, eating/sleeping habits, medical history including immunizations and allergies, and any medications taken regularly. Parents sign to acknowledge the information.

Uploaded by

lyssat83
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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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:


_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Please explain your childs eating habits and schedule:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Please explain your childs sleeping habits and schedule:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Has child had previous experience away from home? Yes


No
if yes explain:
_________________________________________________________________________________________
_________________________________________________________________________________________

Are your childs immunizations up to date? Yes No


if no please explain:
_________________________________________________________________________________________
_________________________________________________________________________________________

Does child have any known health problems? Yes


No
if yes please explain:
_________________________________________________________________________________________
_________________________________________________________________________________________

Does you child have any known allergies? Yes


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

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