Please Fill out This Form Completely. If a Question Does Not Apply to Your Child, Writen/A

Please fill out this form completely. If a question does not apply to your child, writeN/A (not applicable). This application form must be in the provider’s possession on or before the first day your child begins care. Please notify your provider if any of the information changes.

Child’s Full Name:…………………………………….. …………….. Date of Birth: ……………………………..

Child’s Nick Name ………………………………………… Primary Language Spoken: ………………………...

Sex: …………………………... Height: ……………………… Weight …………………………….

Child’s Address: ……………………………………………………………………………………………………….

StreetCityState Zip Code

Name of Parent/Guardian

Mother/Step-Mother ……………………………………,,,,,,,,,. Phone Number……………………………………...

Father/Step-Father ………………………………………,,,,,,,,, Phone Number ……………………......

Guardian …………………………………………...... Phone Number ……………………......

Home Address

Mother/Step Mother …………………………………………………………………………………………………….

…………………………………………………………………………………………………….

Father/Step-Father …………………………………………………………………………………………………….

…………………………………………………………………………………………………….

Guardian ……………………………………………………………………………………………………

……………………………………………………………………………………………………

Work Phone Number

Mother/Step-Mother ……………………………………………. Father/Step-Father ………………………......

Guardian ……………………………………………

Parent’s/Guardian’s location during child care:

Parent/Guardian………………………………………Parent/Guardian ……………………………………...

Where ………………………………………………..Where ………………………………………………..

Tele # ………………….. Cell # ……………………Tele # ………………………… Cell # ……………..

Instructions …………………………………………..Instructions …………………………………………..

………………………………………………………..………………………………………………………..

ADDITIONAL PERSON(S) DESIGNATED BY PARENT/GUARDIAN WHO IS/ARE AUTHORIZED TO BE INFORMED IN AN EMERGENCY AND TO PICK-UP CHILD(REN): All changes must be made in writing and signed by the Parent or Guardian

In the event of an emergency when I may not be reached, the provider may contact the following individuals (in the order given).

1. ……………………………………. Address: ……………………………………………. Cell No. ……………...

2. ……………………………………. Address: …………………………………………….. Cell No. ……………..

I additionally authorize the following individuals to take my child from the child care premises. (It is advised that you notify the provider at the beginning of the day when your child will be picked up by one of the authorized individuals.)

1. ……………………………………. Address: ……………………………………… Tele/ Cell No. ……………...

2. ……………………………………. Address: ……………………………………… Tele/Cell No. ………………

Intended Attendance

DAY / ARRIVAL TIME / DEPARTURE TIME
Monday
Tuesday
Wednesday
Thursday
Friday

Parental Visit Notice

I understand that I may visit this family child care home unannounced at any time during the hours that my child is in care.

Signature ______Date ______

Child’s Pediatrician or Source of Health Care

Name: ______Address: ______

Telephone: ______

Parent’s/Guardian’s Signature: ………………………………………………….Date ……………………………….