Enrollment Form
Child Information Enrollment Date: Disenrollment Date:
Child’s Full Name Date of Birth Nickname
Child’s Full Name Date of Birth Nickname
Address
City, State, Zip Home Phone
Desired Date to Begin Care Full Time Part Time
Child lives with: Mother Father Both Guardian
Parent Contact Info Primary Contact Phone Number:
Parent Name Parent Name
Street Address (if different from child) Street Address (if different from child)
City, State, Zip City, State, Zip
Home Phone Cell Phone Home Phone Cell Phone
Work Place Work Place
Work Phone Ext. Work Phone Ext.
1
Emergency Contact Info – *Please list contacts other than those who live with the child*
The following people are authorized to pick up my child and may be contacted in case of an emergency or illness in the
event I cannot be reached.
Parent/Guardian Signature:
Contact Person 1: Contact Person 2:
Relationship to Child Relationship to Child
Primary Phone Alt. Phone Primary Phone Alt. Phone
Address Address
Contact Person 3: Contact Person 4:
Relationship to Child Relationship to Child
Primary Phone Alt. Phone Primary Phone Alt. Phone
Address Address
Child’s Medical Coverage
Insurance Company Name Member/Policy Number
Policy Holder Name Employer Name
Insurance Company Name Member/Policy Number
Policy Holder Name Employer Name
2
Consent for Medical Care and Treatment
I give permission for the licensed provider or qualified staff to administer first aid/emergency medical treatment to my
child/children.
Parent/Guardian Signature: Date:
When I cannot be contacted, I authorize and consent to medical, surgical, and hospital care, treatment and procedure to
be performed for my child by a licensed physician, health care provider, hospital or aid car attendant when deemed
necessary or advisable by the physician or aid car attendant to safeguard my child’s health. I waive my right of informed
consent to such treatment. I also give my permission for my child to be transported by ambulance or aid car to an
emergency center for treatment. I certify under penalty of perjury under the laws of the State of Washington that this
information is true and correct.
Parent/Guardian Signature: Date:
Additional Authorized Pick-Ups
Name: Primary Phone:
Relationship: Alt. Phone:
Name: Primary Phone:
Relationship: Alt. Phone:
Back-up Care Provider
Name Primary Phone:
Alt. Phone:
Address:
Person’s Not Authorized for Pick-Up Please Note: Childcare provider must have a copy of the legal
custody order in order to detain pick up from a parent.
Name Name
Relationship to Child Relationship to Child
Primary Phone Alt. Phone Primary Phone Alt. Phone
Address Address
3
Child’s Health Info
CHILD'S HEALTH RECORD: (A copy of your child's immunizations and current physical will be needed)
General state of health:
Doctor’s name Doctor’s phone number
Dentists’ name Dentists’ phone number
Are your child's immunizations up to date?
(Please attach a copy of immunizations. This should include the signature of nurse or doctor who administered
medications.)
Does your child have any known allergies?
Are you concerned that your child may be prone to any type of allergies? ___________
Describe:
Does your child have any medical conditions which I should be made aware of?
Is your child on any long-term medications?
Does your child have any speech, hearing or visual problems?
Does your child have any physical disabilities or developmental delays?
Would there be any restrictions to play or activities?
4
About Your Child
Has your child ever been in child care before?
What type (center, family daycare, grandma etc.)
Was it a positive experience?
How does your child feel about daycare and being left by his/her mommy/daddy?
What is your normal method of discipline?
What is your child's temperament? Are they easy going, hard to please, demanding, aggressive, etc?
Does your child usually nap? At what times?
Are there any food restrictions?
What is your child's favorite food?
What food does your child dislike?
Is your child potty trained?
What words does your child use for: Bowel movements Urination
Has your child had experience playing with other children?
What language(s) are spoken at home?
Does your child have any security objects such as a blanket, soother, bottle, toy etc. ?
What are your child's favorite activities, toys, books, or games?
Are there any other comments or information you would like to let me know about?
