Family Day Care Xp-
Child Care Day Care

If you have decided to enroll your child, please fill out form for speedy processing of paperwork. Childs name,age,sex,date of birth,name of person applying,relationship to child,email address,and contact number must be completed for registration to be submitted.

 

Childs Full Name:
Childs Sex:
Childs Age:
Childs Home Address:
City, State, Zip:
Childs Date of Birth:
Childs Home Phone #:
Childs Country/State of Birth:

Name of person applying for child:
Relationship:
Home Phone #:
Daytime Phone#:
Email Address:
Address of Person listed above if different from child:
City, State, Zip:
Job/School Name:

Job/School Address:
Job/School Phone:
Please Provide Income: Per 

Alternate Child Pick Up Information
Escort Information 1
Escort Name:
Escort Address:
Escort City, state Zip:
Escort Phone Number:
Escort Phone Type:

Escort Information 2
Escort Name:
Escort Address:
Escort City, state Zip:
Escort Phone Number:
Escort Phone Type:

Escort Information 3
Escort Name:
Escort Address:
Escort City, state Zip:
Escort Phone Number:
Escort Phone Type:

Escort Information 4
Escort Name:
Escort Address:
Escort City, state Zip:
Escort Phone Number:
Escort Phone Type:

Food And Snacks
Food is offered to your child but they are not forced to eat it. Parent/Guardians will be notified immediately if your child is not eating. The aim of the program is to serve nutritious and well blalanced meals and snacks, please list some foods that fall in this category that your child enjoys to help establish a nutritious but Satisfying menu:

Special Health conditions 1
Condition

Age It began
Treatment/Medications

Special Health conditions 2
Condition

Age It began
Treatment/Medications

Special Health conditions 3
Condition

Age It began
Treatment/Medications

Special Health conditions 4
Condition

Age It began
Treatment/Medications

Special Health conditions 5
Condition

Age It began
Treatment/Medications

Has child ever been operated on? If yes Explain:
Has child ever had a serious accident(borken bone, head injury, fall, poisoning)?
If yes Explain:
Has child ever had a serious illness?If yes Explain:
Does your child have any allergies?
If so what is your child allergic to?

Significant family history
List all that apply (Sickle Cell, Diabetes, Convulsive Disorder, Allergies(specify),Other(specify), Heart Disease, hypertension, Tuberculosis, Vision, Hearing):

Child's Source of Medical Care/Primary Care Physician's Name and Address:
Physician's Telephone:

Child's Sources of Dental Care/Dentist's Name and Address:
Telephone:

Name Of Medical Care Facility/Hospital and Address:
Telephone:

Emergency Data 1
Relationship
Contact Name
Telephone # during child care
Type
Other Telephone #
Type

Emergency Data 2
Relationship
Contact Name
Telephone # during child care
Type
Other Telephone #
Type

Emergency Data 3
Relationship
Contact Name
Telephone # during child care
Type
Other Telephone #
Type

Emergency Data 4
Relationship
Contact Name
Telephone # during child care
Type
Other Telephone #
Type

Agreements:
I consent for my child to take part in neighborhood trips(i.e. library, park, and playground) away from the facility under proper supervision:

In case of accident or injury, I authorize any and all emergency medical, dental, and/or surgical care and hospitalization advised by the physicians, surgeon or hospital (listed on above) necessary for the proper health and well-being and of my child:

I have provided information on my childs special needs (Allergies, Diet, Disabilities, and/or Medical information) to the Provider, as may be necessary to assist the facility in properly caring for my child in case of an emergency:

I agree to review and update this information when ever a change occurs and at least once every six months:


 

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