Use this form to Collect all required about a child enrolling in day care.
Directions: The day care provider gives this form to the child's parent or guardian. The parent or guardian completes the form in its entirety and returns it to the day care provider before the child's first day of enrollment. The day care provider keeps the form on file at the child care facility.

Enrollment Form

General Information
Student Lives With *
Student's Home Address

Home of record

Is the student's home of record a parent, guardian, or any other domicile owned or otherwise provided by someone other than the student? *

Emergency contacts

Custody Documents on file? *

I authorize the child care operation to release my child to leave the child care opereation ONLY with the following persons.
Please list the name and phone number for each .  Children will only be released to a parent or guardian or to a person designed by the parent/guardian after verification of ID.

Consent Information

Check All That Apply
1. Transportation

I give consent for my child to be transported and supervised by the operation's employees: *
2. Field Trips *
3. Water Activities

I give consent for my child to participate in the following water activities *
4. Receipt of Written Operational Policies ( Check All That Apply)

I acknowledge receipt of the facility's operational policies, including those for: *
5. Meals

I understand that the following meals will be served to my child while in care: *
6. Days and Times in Care

My Child is in Care on the following days *

Authorization For Emergency Medical Attention

In the event I cannot be reached to make arragements fo emergency medical care, I authorize the person incharge to take my child to:

Child's Additional Information Section

Child day care operations are public accommodations under thte Americans with Disabilities Act (ADA). Title III. If you believe that such an operation may be practicing discrimination in violation of Title III, you may call the ADA Information at (800) 541-03301 (voice) or (800) 514-0383 (TTY).
Does your child diagnosed with food allergies? *

School Age Children

My child has permission to (check all that apply) *
My child has permission to (check all that apply)

Admission Requirement

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