Childcare Pre-Enrollment Application Order Number Child's full name * Child's Date of Birth * City * Email Address Name(s) of parent(s)/guardian(s) * Mother's employer Employer's address Employer's telephone number List telephone numbers such as beeper, cellular phone, etc. * Name child is known by * Child's Home Address * State * - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Home Telephone Number * Address of parent(s)/guardian(s) * Father's Employer Employer's address Employer's telephone number Instructions regarding how parent/guardian may be reached in an emergency * Person(s) to be contacted in emergency if parent(s)/guardian(s) cannot be reached: Name Relationship to child Address Telephone Name of child's doctor Doctor's address Telephone number Emergency Authorization I give permission for the child care facility to obtain emergency medical treatment, including emergency transportation, for my child if I cannot be reached immediately. I agree to be responsible for any emergency medical expenses incurred. I give permission for the care facility to administer Syrup of Ipecac to my child in accordance with instructions from the poison control center. (If parent/guardian refuses to sign, instructions must be attached stating what procedure the facility is to follow in an emergency. Signature (Please type name) * Date * T-shirt Small Medium Large Child's Preadmission Record (continued) Describe any special needs or instructions below Person(s) the child may be released to: Name Relationship to child Address Telephone number I understand that the Department of Human Resources does not inspect activities away from the child care facility (home or center). The license of the child care facility assumes full responsibility for such activities. Signature of parent/guardian (please type name) * Date * I give permission for my child to participate in: (Choose yes or no and sign each line) Activities away from the facility: * Yes No Transportation provided by the facility: * Yes No Swimming/wading activities provided by the facility: * Yes No Signature of parent/guardian (please type name) * Signature of parent/guardian (please type name) * Signature of parent/guardian (please type name) * Date * Date * Date * Form not valid without signature of child's parent/guardian in each space indicated above
