Garden of Faith Preschool

CHILD CARE APPLICATION FOR ENROLLMENT

Student Information:

Date of Birth*

Sex*

Date of Enrollment*

First Name*

Middle Name

Last Name*

Nickname

Primary Hours of Care*

From*

To*

Family Information:

Mother’s Name

Mother’s Name*

Address*

Home Phone*

Employer*

Address*

Work Phone*

Cell*

Father’s Name

Father’s Name*

Address*

Home Phone*

Employer*

Address*

Work Phone*

Cell*

Custody:

Mother*

Father

Both

Other

Medical Information:

I hereby grant permission for the staff of this facility to contact the following medical personnel to obtain emergency medical care if warranted.

Doctor*

Phone*

Address*

Hospital*

Preference*

Please list allergies, special medical or dietary needs, or other areas of concern:

Emergency Care Plan instructions (if applicable):

Emergency Contacts

Child will be released only to the custodial parent or legal guardian and the persons listed below. The following people will also be contacted and are authorized to remove the child from the facility in case of illness, accident or emergency, if for some reason, the custodial parent or legal guardian cannot be reached:

Name*

Address*

Helpful Information About Child:

Sections 7.1 and 7.2, of the Child Care Facility Handbook, require a current physical examination (Form 3040) and immunization record (Form 680 or 681) within 30 days of enrollment.

Section 7.3, of the Child Care Facility Handbook, requires that parents receive a copy of the Child Care Facility Brochure, "Know Your Child Care Facility” (CF/PI 175-24), or

Section 8.3, of the Family Day Care Home/ Large Family Child Care Home Handbook, requires that parent(s) receive a copy of the family day care home brochure, “Selecting A Family Day Care Home Provider” (CF/PI 175-28).

Section 2.8, of the Child Care Facility Handbook, requires that parents are notified in writing of the disciplinary and expulsion policies used by the child care facility, or

Section 2.3, of the Family Day Care Home/ Large Family Child Care Home Handbook, requires that parents are notified in writing of the disciplinary and expulsion policies used by the family day care provider