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Application for Child Care

Please fill in all areas to submit form.

Child Information

Child's First Name

Child's DOB

Child's Last Name

Proposed Placement Date

Mother/Guardian Information

Mother/Guardian's First Name

Home Phone #

Mother/Guardian's Last Name

Cell Phone #

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

Yes

No

Home Address

City

State

Zip Code

Employer

Work Phone #

Work Hours

Email

Father/Guardian Information

Father/Guardian's First Name

Home Phone #

Father/Guardian's Last Name

Cell Phone #

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

Yes

No

Home Address

City

State

Zip Code

Employer

Work Phone #

Work Hours

Email

Emergency Contact Information

Name of person to call if parents cannot be reached

Relationship to child

Phone

Address

City

State

Zip Code

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

Yes

No

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

Name of person to call if parents cannot be reached

Relationship to child

Phone

Address

Name of person to call if parents cannot be reached

Relationship to child

Phone

Address

Name of person to call if parents cannot be reached

Relationship to child

Phone

Address

Medical Information

Emergency Treatment Facility

Address

Child's Physician

Phone Number

Guardian Name

Parent/Guardian of

Child's Name

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.

Signature

Witness

Date

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

Yes

No

Signature

Date

Disease History (if Any)

Select all that apply to your child.

Measles

Mumps

German Measles

Chicken Pox

Whooping Cough

If your child has asthma or allergies, please list them here.

Does your child have contracted tuberculosis?

Yes

No

Does your child have frequent ear infections?

Yes

No

Does your child have defective heart problems?

Yes

No

Does your child have frequent throat infections?

Yes

No

List other medical information

Child's Developmental Needs

List any physical or emotional problems the child might have.

Child's special food needs:

Medications

Does your chid have problems with the following? Mar all that apply.

Temper Tantrums

Diabetes

Frequent Colds

Biting

Sun Sensitivity

Seizures

Fainting spells

Bed Wetting

Other:

Does your chid require help with the following? Mar all that apply.

Dressing

Undressing

Toileting

Eating

Washing Hands

List your child's favorite games.

List your child's favorite toys.

List your child's favorite food.

Does your child have siblings?

Yes

No

Names of sibling(s)

Type of child care used before:

Other useful information:

Select Location

I, the parent/guardian of this child, understand that I may ask for a conference witht he caregiver(s) as needed.

Signature

Date

Thanks for submitting!

I,

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