Meskwaki Child Care Enrollment Form

Meskwaki Child Care Enrollment Form
Date*

MonthDayYear
Date
Child's Name*

First NameLast Name
Child's Birthdate*

MonthDayYear
Date
Child's Age
Gender*
Nickname(s)?
Child's Primary Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
1 Parent/Guardian's Name *

First NameLast Name
Relationship to Child (Mother, Koko, Aunt, etc.)*
Email
example@example.com
2 Parent/Guardian's Name

First NameLast Name
Relationship to Child (Father, Medo, Uncle, etc.)
Email
example@example.com
Parent 1 Home/Cell Phone Number*
Please enter a valid phone number.
Parent 1 Work Phone Number
Please enter a valid phone number.
Parent 2 Home/Cell Phone Number
Please enter a valid phone number.
Parent 2 Work Phone Number
Please enter a valid phone number.
In the event neither parent/guardian can be contacted, please list two alternate Emergency Contact People below:
Emergency Contact #1*

First NameLast Name
Emergency Contact #1 Phone Number*
Please enter a valid phone number.
Relationship to Child (Grandparent, Uncle, etc.)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact #2

First NameLast Name
Emergency Contact #2 Phone Number
Please enter a valid phone number.
Relationship to Child (Grandparent, Uncle, etc.)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have a backup care provider? If so, please list
Pick Up List:
Pick Up Contact #1*

First NameLast Name
Pick up Contact #1 Phone Number*
Please enter a valid phone number.
Pick Up Contact #2*

First NameLast Name
Pick up Contact #2 Phone Number*
Please enter a valid phone number.
Service Info:
Preferred Start Date*

MonthDayYear
Date
Please list the hours needed below:
Monday

Drop Off TimePick Up Time
Tuesday

Drop Off TimePick Up Time
Wednesday

Drop Off TimePick Up Time
Thursday

Drop Off TimePick Up Time
Friday

Drop Off TimePick Up Time
Child's Health Information
Doctor's Name*
Doctor's Phone Number
Dentist's Name
Dentist's Phone Number
Are your child's immunizations up to date?*

YesNo
Please attach a copy of your child's immunization records. (Contact your provider for needed records.)

Cancelof
Does your child have any known allergies or take medication? If so, please list below:
Are you concerned that your child may be prone to any type of allergies? If so, please describe:
Does your child have any medical conditions which we should be made aware of?
Does your child have any problems with any of the following illnesses?

ConstipationConvulsionsDiarrheaFainting SpellsFrequent ColdsFrequent Ear InfectionsFrequent Sore ThroatsLiceRingwormSkin RashSoilingStomach UpsetsUrinary ProblemsWorms
Has your child had any of these diseases?

AsthmaBronchitisChicken PoxDiabetesHeart DiseaseHepatitisImpetigoMeaslesMumpsGerman MeaslesPolioScarlet FeverTuberculosisWhooping Cough
Would there be any restrictions to play or activities?
Has your child been in child care before?

Yes, in a child care center settingYes, in family daycareYes, with grandparent or family memberNo
If yes, was it a positive experience for them?

YesNo
Heading
Tell us about your child:
Does your child have any food restrictions?
What food does your child dislike?
What is your child's favorite food?
What words do your child use for bowel movements and urination?
Can your child be relied upon to indicate bathroom wishes?
What language(s) are spoke at home?
Does your child have any security objects such as a blanket, soother, bottle, toy, etc?
What are your child's favorite activities, toys, books, or games?
Are there any other comments or information you would like to share about your child?
Any specific concerns?
Signature

Clear
Should be Empty:

Meskwaki Child Care Enrollment Form

Pick Up List:

Service Info:

Child's Health Information

Heading