Application for Day Care Application Date: ____/____/____ M D Y Child�s Name: ___________________________________________ Birth Date: ____/____/____ M D Y Parent(s)/Guardian(s) Name: ______________________________________________________ Address:_______________________________________________________________________ Employment/School Name & Address _______________________________________________ Telephone Numbers: (W) ________________ (H) _________________ (O) ________________ Emergency Contact: Name, Address, & Phone: ________________________________________ Days you require care: Sun.____ Mon.____ Tues.____ Wed.____ Thurs.____ Fri.____ Sat.____ Hours of care required: ____:____ to ____:____ or other _____________________ (school-age) Who can pick up your child: _______________________________________________________ Child�s Doctor: ____________________________________ Phone: ______________________ Health Care Card Number: _______________________________ Expiry Date: ____/____/____ Has child been immunized? Y: _____ N: _____ Does child have any health issues/allergies? ______________________________________________________________________________ ______________________________________________________________________________ What does your child like to eat/drink and describe eating habits/patterns: __________________ ______________________________________________________________________________ ______________________________________________________________________________ Favorite toys/games/activities: _____________________________________________________ ______________________________________________________________________________ Describe child�s behavior/personality/development:_____________________________________ ____________________________________________________________________________________________________________________________________________________________ Napping: Yes____ No____; Toilet trained: Yes____ No____; Attachments: Yes____ No____ _____________________________________________________________________________ Parent Signature:___________________________________________ Child�s Start Date: _____/_____/_____ Child�s Withdrawal Date: _____/_____/_____ M D Y M D Y
