Enrollment Form

Step 1 of 2

Childs #1 Name *

First

Last

Checkboxes *

Male
Female

Date of Birth *

Age of Child *

Childs #2 Name

First

Last

Checkboxes

Male
Female

Date of Birth

mm/dd/yyyy

Age of Child

Childs #3 Name

First

Last

Checkboxes

Male
Female

Date of Birth

mm/dd/yyyy

Age of Child

Parent / Legal Guardians Email *

Parent / Legal Guardian Address *

Address Line 1

Address Line 2

City

State

Zip Code

Mothers Name *

First

Last

Mother's Work Phone

Mothers Cell Phone *

Mother's Work Address

Address Line 1

Address Line 2

City

State

Zip Code

Father's Name *

First

Last

Father's Work Phone

Phone Cell Phone *

Father's Work Address

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact #1 *

First

Last

Contact's Phone *

Contact's Address

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact #2 *

First

Last

Contact's Phone *

Contact's Address

Address Line 1

Address Line 2

City

State

Zip Code

Child(ren)s Living Arrangements *

Both Parents
Mother
Father
Other

Child(ren)s Legal Guardian *

Both Parents
Mother
Father
Other

Name of Legal Guardian (if Other is checked

First

Last

Other than the person signing this contract or an Emergency Contact, Child May be Released to #1

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Relationship to Child(ren)

Other than the person signing this contract or an Emergency Contact, Child May be Released to #2

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Relationship to Child(ren)

Other than the person signing this contractor an Emergency Contact, Child May be Released to #3

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Relationship to Child(ren)

Beginning Date Needing Child Care *

Days Child(ren)s will attend

Monday Through Friday
Partial Week

State Days of week Child(ren) will be attending

Time Child(ren) is to be dropped off or picked up from school. *

Time Child(ren) is to be picked up (10 hour max from drop off time) *

Child(ren)s General State of Health *

Good
Fair
Has health issues

Doctor's Name *

First

Last

Doctor's Phone *

Dentist's Name

First

Last

Dentist's Phone

Are your Child(ren)s immunizations up to date? (Please submit a copy of immunizations to the childcare. This should include the signature of nurse or doctor who administered medications. Child will not be admitted without an up to date immunization record.) *

Does your child/Children have any known allergies? *

Are you concerned that your Child/Children may be prone to any type of allergies? Describe *

Does your Child/Children have rand/or behavioral conditions which we should be made aware of? *

Explain from above and give Child(ren)s name and date of occurances. *

Does your Child/Children have any speech, hearing or visual problems? *

Would there be any restrictions to play of activities? *

My Child(ren) has the following special.... *

The following special accommodation(s) may be required to meet my child's/Children's needs most effectively while at the center. *

My Child(ren)s is/are currently prescribed medication(s) for long-term continuous use and/or has the following preexixting illness, allergies or health conditions. *

Before any medication is dispensed to my child(ren), I will provide a written authorization, which will include date, name of child,, name of medication, prescription number (if any), dosages, date and time of day medication is to be given. Medicine will be in the original container with my child's name marked on it *

I Agree

I acknowledge it is my responsibility to keep my child's records current to reflect any significant changes as they occur, e.g., telephone numbers, work location, emergency contacts, child's physician, child's health status, infant feeding plans and immunization records, etc. The facility agrees to keep me informed of any incidents, including illnesses, injuries, adverse reactions to medications, etc. whick involve my child. *

I Agree

The (facility) Kids University, agrees to obtain written authorization from me before my child participates in routine transportation, field trips, special activities away from the facility, and water related activities occurring in water that is more than two (2) feet deep. *

I authorize the childcare facility to obtain emergency medical care for my child when I am not available.
The Parent Handbook has been made available to me and I agree to abide by the policies and procedures of Kids University
I understand that the facitly will advise me of my child's progress and anything relating to my child's care as well as any individual practices concerning my child's needs. I also understand that my participation is encouraged in facility activities.

Signature of Parent/Guardian *

Date Signed *

Signature of Administrator/Person-In-Charge

Date Signed

Date

Time