Family Childcare Registration

FAMILY CHILDCARE REGISTRATION

Child’s Full Name ______Nickname______

Birth Date:______Date of Enrollment______

Address:______

City______State______Zip Code______

Home Phone______

Mother’s Full Name______

Mother’s Address:______

City______State______Zip Code______

Mother’s Home Phone______

Mother’s Employer______

Employer’s Address______City______State_____

Mothers Occupation:______

Hours at work:______to ______. Days at work:______

Work Phone:______ext.____ Pager or Cell #______

Father's Full Name:______

Father’s Address______

City______State______Zip Code______

Father’s Home Phone______

Father’s Employer______

Employer’s Address______City______State_____

Father’s Occupation:______

Hours at work:______to ______. Days at work:______

Work Phone:______ext.____ Pager or Cell #______

(Next Section Fill out only if applicable)

Parent/Guardian with legal custody:______Decree on file? Yes or No (circle)

Parents are: Married /Divorced / Separated /Widowed /Single

Emergency Contact’s and Persons Authorized to remove child from home

Primary Emergency Contact(other than parents/guardian):

Name______

Home Phone:______Work Phone:______

Emergency Contact Address______City______State______

Relationship to Child:______

Secondary Emergency Contact(other than parents/guardian):

Name______

Home Phone:______Work Phone______

Second Emergency contact address:______City______State______

Relationship to Child______

Person(s) authorized to pick up my child(Besides parents/guardians or emergency contacts:

#1______

#2______

#3______

(With prior notice from parent/guardian and proper ID only)

Daycare References:

Has your child ever been in daycare before?______

If so, why did you leave?______

Name of Previous Provider:______

Phone number of Previous Provider:______

Emergency Release

Consent to Emergency First Aid & Transportation

I hereby give my permission that my child, may be given emergency treatment by Daycare Name. I also give permission for my child to be transported by car or ambulance to an emergency center for treatment.

Parent/Guardian Signatures:______

Date______

Consent to Medical Care and Treatment

In the event that I cannot be contacted immediately, medical or surgical treatment can be administered to my child in the case of an accident or emergency, as prescribed by a treating physician.

Parents/Guardians Signatures:______Date:______

Daycare Namewill not be responsible for paying for the child's health care.

1. Child's Physician:______Phone:______

2. Preferred Hospital:______Phone:______

3. Insurance Company:______Policy #______

4. Regular Medications:______

5. Blood Type:______

6. Medicine allergic to:______

7. Food Allergies:______

8. Any other Allergies:______

9. Any special health conditions:______

Overview Of Care Needs

Number of days per week child care is needed:______

Days of week care is needed:______

I will bring my child to day care at:___ AM/___PM

I will pick up my child:___ AM/___PM...... Weekly fee:_____Late fee:______

A last weeks fee / security deposit of: $______must accompany this registration.

(This fee will be applied to your child's final bill.)

Comments:

Signatures:

Provider:______Date:______

Parent/Guardian:______Date:______

Parent/Guardian______Date:______

(I understand that this is a legally binding document, and have read it and understand it)