Clarian Place Child Care & LC

Enrollment Application

Entrance Date:                                                            4 digit I.D. #

Withdrawal Date

Child’s Name

Sex:

Age:

D/O/B

Home Address                                                                          C/S/Z

Mother’s Name/Home Address, if different from child’s

Telephone #

Place of Employment/Address of Employment

Work Phone #

Father’s Name/Home Address, if different from child’s

Telephone #

Place of Employment/Address of Employment

Work Phone #

Alternate Phone #s:

Cellular Phone #

Pager #

Child’s Living Arrangements:

Both parents

[  ]

Mother

[  ]

Father

[  ]

Other

[  ]

Child’s Legal Guardian(s)

Both parents

[  ]

Mother

[  ]

Father

[  ]

Other

[  ]

The child may be released to the person(s) signing this agreement or the to following:

1.                                              Address/Phone #

2.                                             Address/Phone #

Persons to contact in the case of an emergency when parents cannot be reached:

1.                                              Address/Phone #

2.                                             Address/Phone #

Name of public or private school child attends, if any:

Child’s Physician or Clinic’s Name (Child’s Primary Health Source)         Office Phone #:                                                          

My child is currently on medication(s) prescribed for long-term continuous use and/or has the following pre-existing illness, allergies, or health concerns: ______________________________________________

________________________________________________________________________________

Signed:

Parent(s)/Guardian

Date: