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QUALITY CHILDCARE
Enrollment Application
ENROLLMENT APPLICATION
PLEASE COMPLETE
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Child's Full Name
*
Date Of Birth
Home Address
Phone Number
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Mother's Full Name
Father's Full Name
Place Of Employment
Work Address
Work Phone Number
Email
Place Of Employment
Work Address
Work Phone Number
Email
List any special needs your child may have
Read and INITIAL the appropriate answer to the following items.
I have been given a copy of and have read the MSDH Regulation Summary for Parents
*
Yes
No
A completed 121 immunization Compliance Form is on file in the facility before the child attends
*
Yes
No
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In case of an emergency and the PARENTS can't be reach, contact the following:
Name
Phone Number
Relationship
Address
Name
Phone Number
Relationship
Address
The following people are authorized to pick up and drop off my child/children
Name
Name
Name
Name
Does your child have any allergies? Please list, including food, if necessay
Complete each of the following sections by checking either yes or no
My child may be photographed at the child care center
*
Yes
No
My child may take approved field trips sponsored by the child care center
*
Yes
No
The childcare center may give my child emergency medical treatment if needed
*
Yes
No
My child is toliet train
*
Yes
No
If no, my child will eat before coming into the center
Record updated and signed by parent (one a year)
*
I agree
Submit Application
Date
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