Enrollment Forms — Kiddie Farms Child Development Center

Child's Application for Enrollment — Page 1

Child information, family details, and emergency care authorization.

Application Date

Date of Enrollment

Child's Last Name *

Child's First Name *

Nickname

Birth Date *

Address *

Zip Code *

Father/Guardian's Name

Father Cell Phone

Father Email Address

Father Address

Father Zip Code

Father Where Employed

Father Business Phone

Mother/Guardian's Name

Mother Cell Phone

Mother Email Address

Mother Address

Mother Zip Code

Mother Where Employed

Mother Business Phone

Any known allergies? *

If yes, explain allergies

Additional info to assist child in group settings

Child's Doctor Name

Doctor Office Phone

Doctor Address

Child's Dentist Name

Dentist Office Phone

Dentist Address

Hospital Preference

Hospital Phone

Emergency Contact 1 — Name *

Emergency Contact 1 — Relation *

Emergency Contact 1 — Best Number *

Emergency Contact 2 — Name

Emergency Contact 2 — Relation

Emergency Contact 2 — Best Number

Persons authorized to pick up child

Parent/Guardian Signature *

Signature Date *