Infant Enrollment Application

Entrance Date:

Withdrawal Date:

Child’s Name:

Sex:

Age:

Date of Birth:

Home Address:

Home Phone:

City:

State:

Zip:

Father’s Name:

Father’s Home Address (if different from child’s):

Father’s Home Phone:

Father's City:

Father's State:

Father's Zip:

Father’s Place of Employment:

Work Phone:

Employer’s Street Address:

Employer’s City/State/Zip:

Mother's Name:

Mother’s Home Address (if different from child’s):

Mother’s Home Phone:

City:

State:

Zip:

Mother’s Place of Employment:

Work Phone:

Employer’s Street Address:

Employer’s City/State/Zip:

Father Email:

Mother Email:

Child’s Living Arrangements:

Both Parents

Mother

Father

Other

Child’s Legal Guardian(s):

Both Parents

Mother

Father

Other

Number of persons to contact/Pick-up in the case of emergency when parent or guardian cannot be reached:

Contact Person #1

Contact Person #1 Phone

Contact Person #2

Contact Person #2 Phone

Contact Person #3

Contact Person #3 Phone

Name of Public or Private School child attends, if any:

Phone of Public or Private School child attends:

Fax number of Public or Private School child attends:

Child’s Medical Information

Child’s doctor or clinic name:

Doctor/Clinic Phone Number:

Doctor/Clinic Fax Number:

My child has the following special needs:

The following special accommodation(s) may be required to most effectively meet my child’s needs while at the center:

My child is currently on medication(s) prescribed for long-term continuous use and/or has the following pre-existing illness, allergies, or health concerns:

Signed:

Clear

Signed Date: