Enrollment Forms — Kiddie Farms Child Development Center

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Child's Application for Enrollment — Page 2

Detailed family, authorized contacts, and health care information.

Date Application Completed

Date of Enrollment

Child's Last Name *

Child's First Name *

Child's Middle Name

Nickname

Date of Birth *

Child's Physical Address *

Child lives with

Father/Guardian's Name

Father Home Phone

Father Address (if different from child)

Father Zip Code

Father Work Phone

Father Cell Phone

Mother/Guardian's Name

Mother Home Phone

Mother Address (if different from child)

Mother Zip Code

Mother Work Phone

Mother Cell Phone

Authorized Contact 1 — Name

Authorized Contact 1 — Relationship

Authorized Contact 1 — Address

Authorized Contact 1 — Phone

Authorized Contact 2 — Name

Authorized Contact 2 — Relationship

Authorized Contact 2 — Address

Authorized Contact 2 — Phone

Authorized Contact 3 — Name

Authorized Contact 3 — Relationship

Authorized Contact 3 — Address

Authorized Contact 3 — Phone

Is a medical action plan attached? *

Allergies, symptoms, and type of response required

Health care needs, concerns, symptoms, and response

Particular fears or unique behavior characteristics

Medications taken for health care needs

Other medical information for safe treatment

Health Care Professional Name

Health Care Professional Office Phone

Hospital Preference

Hospital Phone

Parent/Guardian Signature *

Parent/Guardian Signature Date *

🌻 Enroll Your Child

Child's Application for Enrollment — Page 2