all_about_kidz-child_application.docx | |
File Size: | 66 kb |
File Type: | docx |
Note: Please download the file above and email or mail to:
All About Kidz-NC Child Care Center
1016 Martin Luther King Drive, Fairmont NC 28340
Email:[email protected]-----Website: http://aakidznc.weebly.com
CHILD’S APPLICATION FOR CHILD CARE
To be completed and placed on file prior to enrollment
Application Date: ____________________________________ Date of Enrollment: __________
Name of Child: _____________________________________________ Birth date: ________________
(Last) (First) (MI) (Nickname)
Address: _____________________________________________________Zip Code: __________________
INFORMATION ABOUT THE FAMILY:
*Father/Guardian’s Name: ____________________________________ Home Phone: _________________
Address: _____________________________________________________Zip Code: _________________
Where Employed:___________________________________________Business Phone:_______________
*Mother/Guardian’s Name: ______________________________________Home Phone_______________
Address: _________________________________________ Zip Code____________________________
Where Employed: ______________________ Business Phone___________________________________
Insurance Carrier Policy # _________________________________________
INFORMATION ABOUT YOUR CHILD:
Does your child have any known allergies: No_____ Yes______Explain:________
Does your child have any chronic illnesses/conditions: No ______ Yes_________
Explain:____________________________________________________________
Please give any information concerning your child which will be helpful in his experience in group setting (such as play, eating and sleeping habits, special fears, special likes or dislikes). ____________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
EMERGENCY CARE INFORMATION:
Name of child’s doctor: _____________________________________________Office Phone____________
Address ________________________________________________________________________________
Hospital preference________________________________________________Phone__________________
If neither father nor mother (or guardian) can be contacted, call (please list relationship):
Name _________________________________Home Phone___________________Office Phone_________
Name ________________________________Home Phone______________________Office Phone_______
If you cannot call for your child, please give the names of persons to whom the child can be released:
_________________________________________________
Ø I agree that the operator may authorize the physician of his/her choice to provide emergency care in the event that neither I nor the family physician can be contacted immediately.
__________________________________________________________________
(Signature of Parent) (Date)
Ø I, as the operator, do agree to provide transportation to an appropriate medical resource in the event of emergency. In an emergency situation, other children in the facility will be supervised by a responsible adult. I will not administer any drug or any medication without specific instructions from the physician or the child’s parent, guardian, or full-time custodian. Provisions will be made for adequate and appropriate rest and outdoor play.
__________________________________________________________________
(Signature of Operator) (Date)
1016 Martin Luther King Drive, Fairmont NC 28340
Email:[email protected]-----Website: http://aakidznc.weebly.com
CHILD’S APPLICATION FOR CHILD CARE
To be completed and placed on file prior to enrollment
Application Date: ____________________________________ Date of Enrollment: __________
Name of Child: _____________________________________________ Birth date: ________________
(Last) (First) (MI) (Nickname)
Address: _____________________________________________________Zip Code: __________________
INFORMATION ABOUT THE FAMILY:
*Father/Guardian’s Name: ____________________________________ Home Phone: _________________
Address: _____________________________________________________Zip Code: _________________
Where Employed:___________________________________________Business Phone:_______________
*Mother/Guardian’s Name: ______________________________________Home Phone_______________
Address: _________________________________________ Zip Code____________________________
Where Employed: ______________________ Business Phone___________________________________
Insurance Carrier Policy # _________________________________________
INFORMATION ABOUT YOUR CHILD:
Does your child have any known allergies: No_____ Yes______Explain:________
Does your child have any chronic illnesses/conditions: No ______ Yes_________
Explain:____________________________________________________________
Please give any information concerning your child which will be helpful in his experience in group setting (such as play, eating and sleeping habits, special fears, special likes or dislikes). ____________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
EMERGENCY CARE INFORMATION:
Name of child’s doctor: _____________________________________________Office Phone____________
Address ________________________________________________________________________________
Hospital preference________________________________________________Phone__________________
If neither father nor mother (or guardian) can be contacted, call (please list relationship):
Name _________________________________Home Phone___________________Office Phone_________
Name ________________________________Home Phone______________________Office Phone_______
If you cannot call for your child, please give the names of persons to whom the child can be released:
_________________________________________________
Ø I agree that the operator may authorize the physician of his/her choice to provide emergency care in the event that neither I nor the family physician can be contacted immediately.
__________________________________________________________________
(Signature of Parent) (Date)
Ø I, as the operator, do agree to provide transportation to an appropriate medical resource in the event of emergency. In an emergency situation, other children in the facility will be supervised by a responsible adult. I will not administer any drug or any medication without specific instructions from the physician or the child’s parent, guardian, or full-time custodian. Provisions will be made for adequate and appropriate rest and outdoor play.
__________________________________________________________________
(Signature of Operator) (Date)