Nana and Papa's House Day Care

APPLICATION FORM

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_____

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Emergency Contact Person in addition to parents. They must be within a 20-mile radius.

Name/relationship______________________________________________________Phone___________________ Name/relationship______________________________________________________Phone___________________

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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_________________

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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 _________________

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