Application for Child Care

Please fill in all areas to submit form.

Child Information

Mother/Guardian Information

Would you like to receive important notifications concerning your child via text messaging?

Father/Guardian Information

Would you like to receive important notifications concerning your child via text messaging?

Emergency Contact Information

Is this person authorized to take this child from EDJ Child Enrichment Center?

List all other adults who are authorized to bring and/or take the child from EDJ Child Enrichment Center

Medical Information

Parent/Guardian of

do hereby give my consent to the

Director of EDJ Child Enrichment Center or the duly representative for said child to receive medical or surgival aid as may be deemed necessary and expedient by a duly licensed or recognized physician or surgeon in case of an emergency when the parents cannot be reached in a reasonable length of time. Consent is also given for the Director or his duly appointed representative to transport said child for emergency medical treatment, if a parent or Mobile Emergency Medical Service vehicle cannot respond promptly.

Do you give the Diretor of the Child Care Facility or appointed representative permission to give your child acetaminophen? By aggreeing, you understand that you will be notified that the medication has been administered

Disease History (if Any)

Select all that apply to your child.
Does your child have contracted tuberculosis?
Does your child have frequent ear infections?
Does your child have defective heart problems?
Does your child have frequent throat infections?

Child's Developmental Needs

Does your chid have problems with the following? Mar all that apply.
Does your chid require help with the following? Mar all that apply.
Does your child have siblings?

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