Child's Full Name____________________________________________________________________________
Birth date__________________
Nickname __________________________
HomeAddress_______________________________________________________HomePhone_______________
Mother's Name______________________________________________________ Occupation
______________
Place of employment _________________________________________________ Work Phone _____________
Employer’s Address __________________________________________________________________________
Work Hours _____________________
until ___________________________
Length of employment ________ Estimated date of transfer __________Cell phone
or Beeper _____________
Father's Name
_______________________________________________________ Occupation
______________
Place of employment _________________________________________________ Work
Phone______________
Work Hours _____________________
until ____________________________
Length of employment ________ Estimated date of transfer __________Cell phone
or Beeper _____________
Parent/Guardian with legal custody: ____________________________________________________________
(Please initial)
Parents are: Married_____
Divorced_____
Separated_____ Single_____
If parents are separated or divorced, please indicate whether the other parent
has permission to have contact with the child at Daycare, and whether or not
he/she is allowed to pick up the child. (If there is a no contact order for
the non-custodial parent, I will need to have a copy of the paper work).
(Please initial) Contact: YES_____NO_____ Pick Up: YES_____ NO_____ NOT APPLICABLE_____
***
Emergency Contact Person in addition to parents. They must be within a 20-mile radius.
Name/relationship______________________________________________________Phone___________________Name/relationship______________________________________________________Phone_______________
***
Other than you, who has permission to pick up your child? Any persons not listed will not be allowed access to your child. Anyone other than the parents will be required to show photo identification at pick up. Anyone (including parents) should have proper child restraints for transportation.
Name________________________________________________________________Phone_________________
Name________________________________________________________________Phone_________________
***
Has your child been in day care before? If yes please answer the following. YES ( ) NO ( )
Child's last Daycare Provider
information:
Name _________________________________________________________________ Phone
_______________
Dates attended: from ___________________________________ to __________________________________
Why was care terminated?
_________________________________________________________________
May I contact them for a reference? YES ( ) NO ( )
Parent/Guardian Signature _____________________________________________________ Date ___________
Date child entered care _____________________________________Date child left care _________________