Child’s Application For Enrollment – Children’s Choice Drop-In Enrichment Center

To be completed, signed, and placed on file in the facility on the first day and updated as changes occur and at least annually

CHILD INFORMATION

Full Name:

Date of Birth:

Address:

Child lives with:

Father/Guardian’s Name:

Home Phone:

Address (if different from child’s):

Zip Code:

Work Phone:

Cell Phone:

Mother/Guardian’s Name:

Home Phone:

Address (if different from child’s):

Zip Code:

Work Phone:

Cell Phone:

CONTACTS:

Name:

Relationship:

Address:

Phone Number:

Name:

Relationship:

Address:

Phone Number:

Name:

Relationship:

Address:

Phone Number:

HEALTH CARE NEEDS:

Yes

List any allergies and the symptoms and type of response required for allergic reactions:

List any health care needs or concerns, symptoms of and type of response for these health care needs or concerns:

List any particular fears or unique behavior characteristics the child has:

List any types of medication taken for health care needs:

Share any other information that has a direct bearing on assuring safe medical treatment for your child:

EMERGENCY MEDICAL CARE INFORMATION:

Name of health care professional:

Office Phone:

Hospital preference:

Phone:

I, as the parent/guardian, authorize the center to obtain medical attention for my child in an emergency. Signature of Parent/Guardian:

Date:

Home

About

Services

Applications

Contact

CHILD INFORMATION