ENROLLMENT FORM FOR SUE’S HOME AWAY FROM HOME FAMILY CHILD CARE

Child's Full Name:__________________________Nickname:_____________

Birthdate:_____________________________

Address:_______________________________Home Phone:_________________

Mother's Full Name:___________________________________

Address:__________________________Home Phone:______________

Mother's Occupation:___________________________Employer name____________________

Work Address:_________________________________________Hours at work:____ to ____.

Work Phone:_________ ext.____ Pager or Cell #___________

Mother’s e-mail address _________________________________ is this at __home or ___ work

Father's Full Name:______________________

Home Phone:________________Address:_________________________________________

Occupation:______________Employer Name:__________________________

Work Address:_________________________Hours at work:_____ to ______

Work Phone:__________ ext____ Pager or Cell #__________

Father’s e-mail address __________________________ is that at ___home or ___work

If parent needs to be contacted, which parent called first? MOM or DAD

(Fill out only if applicable)

Parent/Guardian with legal custody:_______________

Parents are: Married /Divorced / Separated /Widowed /Single

Primary Emergency Contact(other than parents/guardian):______________________

Home Phone:_________________ Work Phone:_________________

Emergency contact address____________________________

Relationship to Child:______________________

Secondary Emergency Contact(other than parents/guardian):___________________________

Home Phone:_____________ Work Phone:_____________

Second Emergency contact address:___________________________________

Person(s) authorized to pick up my child(Besides parents/guardians or emergency pick ups):___________________________________________________________

(With prior notice from parent/guardian, and picture ID upon arrival)

Daycare References:

Has your child ever been in daycare before?_________

If so, why did you leave?_____________________________________________________

Name of Previous Provider:______________Phone number of Previous Provider:________

Medical Information

Physician’s Name__________________________ Phone___________________________

Name of Clinic ____________________________________

If unavailable, another physician may treat my child yes ________ No___________

Medical Insurance Company ______________________________ policy No. ____________

Dentists Name _____________________________ phone ____________________________

If unavailable, another Dentist may treat my child ___________________________________

Overview

Number of days per week child care is needed:______________

Days of week care is needed:___________________________________I will bring my child to day care at:___ AM/___PM

I will pick up my child:___ AM___PM____Weekly fee:_____Late fee:_____

Comments:

Signatures:

Provider:______________________Date:_____________

Parent/Guardian:______________________Date:______________________________

(I understand that this is a legally bindin