APPLICATION FOR CHILD CARE

For Center Use Only:

Date of admission ____________

Age at admission:_____________

CHILD INFORMATION:

Child's name: _________________________________________________

Date of birth: _____/_____/____ Place of birth:________________________

Home Address:___________________________________________________

Phone: __(____)____________

Child's Identifying Information (required by the Office For Children)

Sex: ____ Race: ______________ Height:________

Weight:__________ Hair color:____________ Eye color:____________

Other identifying marks: ___________________________________________

Primary language spoken at home:__________________________

PARENT / GUARDIAN INFORMATION:

Name:________________________ Name:___________________________

Relationship:___________________ Relationship:______________________

Home Address:_________________ Home Address:_____________________

_____________________________ _________________________________

Home Phone: ( )_____________ Home Phone: ( )_______________

Place of Employment: ________________ Place of Employment_______________

Address: _________________________ Address:________________________

_________________________________ _______________________________

Work Phone ( )_______________ Work Phone_(_____)______________

Hours at work:________________ Hours at work:___________________

EMERGENCY CONTACTS:

Name:___________________________________________

Address:___________________________________________________________

Phone:_( )______________

Relationship to child:_____________________________________

Name:___________________________________________

Address:_____________________________________________________________

Phone:__(____)_______________

Relationship to child:_____________________________________

Physician's Name:_______________________________________

Address:____________________________________________________________

Phone: ( )______________

Hospital of choice:_____________________________________

Other persons authorized to pick up your child from Childcare:

Name:_________________________________

Address:________________________________________________________

Phone:_(____)______________

Driver's License #_________________________

Name:_________________________________

Address:_________________________________________________________

Phone:__(____)_______________

Driver's License #_________________________

______________________________________ _______________

Parent's/Guardian's Signature Date