Child Admission Record
Date of Enrollment_______________
1. Child’s name______________________ Date of Birth_______________________
2. Nickname ____________________________
3. Home address_______________________________________________
4. Telephone____________________________
5. Cell phone____________________________
6. Father’s or guardians name_____________________________________
7. Address if different from child’s ____________________________________________________
Telephone_____________________________
8. Where Employed_____________________________________________
Business phone #_______________________
Address of the Employer_____________________________________________
9. Mother or guardians name______________________________________
10. Address if different from the child’s
________________________________________________________
10. Where Employed______________________________________________
Business phone________________________
Address of Employer_______________________________________________
11. How many persons responsible for the child be reached while child is at child care facility? ____________________________________________________
12. If neither parent or guardian can be reached in case of emergency call?____________________________________________________
13. Person(s) designated to pick up or deliver child(Include name address and phone of the person is not listed above)
____________________________________________________
14. Person(s) not permitted to call for the child
15. Child’s doctors name _______________________________________________
Address______________________________________________
Telephone____________________________
16. Child’s Dentist name _______________________________________________
Address ________________________________________________________
Telephone____________________________
17. Child’s Hospital of choice____________________________________________
18. Other children in the family(Include name, age and sex for each)____________________________________________________
19. Other adults in the family (list relation to child) ____________________________________________________
20. Please give any information concerning your child which will be helpful to the child care provider
Play habits________________________________________________
Eating habits________________________________________________
Sleeping pattern______________________________________________
Fears________________________________________________
Likes and dislikes_______________________________________________
Others______________________________________________
21. What illnesses has this child had in the past month? ____________________________________________________
22. What treatment was given_____________________________________________
23. What was the last prescription medicine given to the child? ____________________________________________________
24. Has your child had any illnesses in the last 24 hours? If yes explain ____________________________________________________
25. This application must be accompanied with a signed medical statement before
coming to daycare.
Signature of parent or guardian
___________________________
Printed name of parent or guardian
_____________________________
About Your Child
Dislikes?
Favorite toy, game or activity?
Is your child toilet trained?
How does your child express anger?
Does your child have any fears?
When your child is upset what helps Comfort him or her?
How does your child go down for a nap?
Do they have a special blanket or toy for nap?
Special family situations (Custody specifications, problems arising from situation)?
Anticipated adjustment problems?
Previous childcare the child has attended?
Expectations for Lollipop Kid’s daycare?
Other Comments?
Emergency Contacts
Primary Emergency Contact (other than parent or guardian)
Home Phone ____________________________ Work Phone ______________________
Relationship with Child __________________________________________________
Address ________________________________________________________
Secondary Emergency Contact (other than parent or guardian)
________________________________________________________
Home Phone____________________________ Work Phone ______________________
Relationship with Child ____________________________________________________
Address ________________________________________________________
Persons authorized to pick up my child (besides parent, guardian or emergency)
Name ____________________________________
Comment ________________________________________________________
Kid Code: ______________________________ (Secret word between parent and child for identification and pick up)
Person (s) not authorized to pick up child
Name _______________________________________________________
Comments ________________________________________________________
Authorization for emergency medical care
I __________________________________ hereby give my permission to ____________________ to call for medical or surgical care for my child, ______________________, should an emergency arise. It is understood that a conscientious effort will e made to locate me before emergency action will be taken, but if this is not possible the expenses of emergency medical treatment or care will be accepted by me.
___________________________ ____________________________
Parent/Guardian Parent/Guardian
___________________________ ____________________________
Date Date
___________________________ ____________________________
Notary Date Expiration Date
Permission for trips
I give permission for my child to go on trips away from the premises of the child care facility, in the company of a responsible adult, whether on foot or vehicle.
___________________________ ____________________________
Parent/Guardian Parent/Guardian
___________________________ ____________________________
Date Date
Photo Release
Photographs are taken on different occasions such as birthdays, holidays, outings and special occasions. We use these pictures in our daycare home for arts & crafts, gifts, albums and our daycare website.
Child’s(ren) Name: _________________________________
Please mark the appropriate boxes:
( ) I give my permission for pictures of my child(ren) to be taken
( ) I do not want my child’s(ren) picture taken
( ) I give my permission for pictures of my child(ren) to be used on Miss Shannon's website
( ) I do not want pictures of my child(ren) to be used on Miss Shannon's website
Parent’s Signature: _________________________________
Date: ___________________