CHILD CARE ENROLLMENT FORM

Child Full Name:________________________ Birth Date: ________________________
Address: _____________________________ Home Phone: ______________________
City: ______________________ State:________ Zip: ______

Mother's Full Name:________________________ Home Phone: _________________
Address: ___________________________________
City: ______________________ State:___________ Zip: ______
Name of Employer: ____________________________ Work Phone:_____________
Business Address: _____________________________ Ext:_____________
Work Hours: ________________________________ Cell Phone: ______________

Father's Full Name:________________________ Home Phone: _________________
Address: ___________________________________
City: ______________________ State:___________ Zip: ______
Name of Employer: ____________________________ Work Phone:_____________
Business Address: _____________________________ Ext:_____________
Work Hours: ________________________________ Cell Phone: ______________

Guardian Other Than Above/ Full Name:________________________
Home Phone: ______________________
Address: ___________________________________
City: ______________________ State:____________ Zip: ______
Name of Employer: _____________________________ Work Phone:_____________
Business Address: ______________________________ Ext:_____________
Work Hours: _________________________________ Cell Phone: ______________

Parent or Guardian with legal custody: _________________________
Parents are: Married____________ Divorced:________ Seperated:__________
Widowed:_________ Single:________

Primary Emergency Contact (other than parents or guardian): _________________________
Home Phone: __________ Work Phone: _________ Relationship to Child: ______________ Address:_____________________________________________________
Secondary Emergency Contact (other than parents or guardian): ___________________
Home Phone: __________ Work Phone: __________ Relationship to Child: ______________ Address:___________________________________________________

Person(s) authorized to pick up my child: (Besides parents, guardians, or emergency pick ups)
Name: _______________________________ Name: _______________________________
Name: _______________________________ Name: _______________________________
Person(s) NOT authorized to pick up my child:
Name: _______________________________ Name: _______________________________
Name: _______________________________ Name: _______________________________