Enrollment


	Student Information


Date of Birth*		Sex*	MaleFemale	Date of Enrollment*


First Name*				Last Name*
Middle Name*				Nickname*
Address*
Address2
City*		St		Zip


	Primary Hours of Care:	From		To


	Days of the Week in Care:		MTWThFSaSu


Meals Typically Served While in Care:	BrAM SnackLunchPM SnackSupEve Snack


	Family Information


Child Lives With


	Mother's Information		Father's Information
Name		Name
Address		Address
Phone		Phone
Employer		Employer
Address		Address
Phone		Phone
Cell		Cell


	Medical Information


*			I hereby grant permission for the staff of this facility to contact the following medical personnel to obtain emergency medical care if warranted.


Doctor		Address		Phone
Doctor		Address		Phone
Doctor		Address		Phone


Hospital Preference


	Please List allergies special medical or dietary needs, or other areas of concern:


	Contacts


	Child will be released only to the custodial parent or legal guardian and the persons listed below. The following people will also be contacted and are authorized to removed the child from the facility in case of illness, accident or emergency, if for some reason, the custodial parent or legal guardian cannot be reached


Name		Address		Work#		Home#
Name		Address		Work#		Home#
Name		Address		Work#		Home#
Name		Address		Work#		Home#