Sample Childcare Enrollment

Enrollment Information

Child 1
Full name: _____________________________________________________________

Birthday: _____________________ Sex: M F

Primary days and hours of care: ____________________________________________

Does the child or any member of his/her immediate family have any food allergies?


Does the child have any skin sensitivities?


Does the child have any specific medical needs?



Child 2
Full name: _____________________________________________________________

Birthday: _____________________ Sex: M F

Primary days and hours of care: ____________________________________________

Does the child or any member of his/her immediate family have any food allergies?


Does the child have any skin sensitivities?


Does the child have any specific medical needs?



Child 3
Full name: _____________________________________________________________

Birthday: _____________________ Sex: M F

Primary days and hours of care: ____________________________________________

Does the child or any member of his/her immediate family have any food allergies?


Does the child have any skin sensitivities?


Does the child have any specific medical needs?



Parent or guardian's name(s): ______________________________________________

Home Address: _________________________________________________________

Home phone number: (_____)_____________________

Work phone number: (_____)_____________________

Other phone number: (_____)_____________________

Other phone number: (_____)_____________________


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 daycare home in case of illness, accident, or emergency, if for some reason the custodial parent or legal guardian cannot be reached:

Name: _____________________ Relation to child: _____________________

Phone number: (_____)_____________________
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Name: _____________________ Relation to child: _____________________

Phone number: (_____)_____________________
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Name: _____________________ Relation to child: _____________________

Phone number: (_____)_____________________






Parent's Signature: ________________________________ Date: _______________