Parent/Guardian Signature

Date

GROUP CHILD CARE AND SCHOOL AGE CHILD CARE
CHILD'S ENROLLMENT FORM

Program:	Group Child Care:	School Age Care:
Child's Name:	Eye Color:	Skin Color:
Home Address:	Hair Color:	Height:
Telephone:	Sex:	Weight:
Date of Admission:	Age at Admission:
Date of Birth:	Primary Language:
Identifying Marks:
Allergies / special diets:
PARENT/GUARDIAN INFORMATION:
Parent/Guardian Name:	Parent/Guardian Name:
Relationship to child:	Relationship to child:
Home Address:	Home Address:
Home Telephone #:	Home Telephone #:
Bus. Name:	Bus. Name:
Bus. Address:	Bus. Address:
Bus. Telephone #:	Bus. Telephone #:
Hours at Work:	Hours at Work:
ADDITIONAL INFORMATION:
Child's Physician/Clinic:
Address:	Phone:
Chronic health conditions:
Special limitations or concerns:
SCHOOL AGE ONLY
Current School:	School Address:

I certify that documentation of physical examination and immunizations in accordance with public school health requirements, and lead poisoning screening in accordance with public health requirements are on file at my child's school. Parent/Guardian initials: