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Childcare Enrollment Application

Child's Full Name

Date of Birth * required

Home/Cell Phone

Home Address

Mother/Guardian

Please check if this parent has primary custody

Please check if court documentation recieved

Place of Employment

Father/Guardian

Please check if this parent has primary custody

Please check if court documentation recieved

*If custody is shared by both parents/guardians, the facility will abide by documentation provided on this enrollment application.

Thank you! We’ll be in touch.

Childcare Enrollment Application

Child's Full Name

Child's Date of Birth * required

Home/Cell Phone

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Country

Mother/Guardian

Please check if this parent has primary custody

Please check if court documentation recieved

Place of Employment

Work Phone Number

Work Address

Email Address

Cell Phone

Father/Guardian

Please check if this parent has primary custody

Please check if court documentation recieved

Place of Employment

Work Phone Number

Work Address

Email Address

Cell Phone

*If custody is shared by both parents/guardians, the facility will abide by documentation provided on this enrollment application.

List any special needs your child may have:

Does your child have any allergies? Please list:

Read, check and sign to confirm the following: * Required

I have been informed that this Daycare Center does NOT provide liability insurance for my child.

I have been given a copy of and have read the MSDH Regulation Summary for Parents.

I have been given and have read and understand the facility's Parent Handbook.

Complete 121 Immunization Compliance Form is on file in the facility before the child attends.

Your Signature

In case of emergency and the Parents/Guardians cannot be reached, please contact:

1.

Name

Phone

Relationship

Address

2.

Name

Phone

Relationship

Address

3.

Name

Phone

Relationship

Address

The following people are authorized to pick-up and drop-off my child/children:

Name

Name

Name

Name

Name

Name

Select the following approved actions and sign to authorize answers. * Required

My child may be photographed at the childcare center

My child's picture may be used in media, i.e., Facebook, etc.

My child may take approved field trips sponsored by the center

The center may obtain emergency medical treatment for my child if needed

Your Signature

My child is toilet trained.

If no, a consultation between the parent and caregiver is required to be documented prior to toilet training and kept on file.

My child will eat breakfast/morning snack at the center.

If no, my child will eat BEFORE coming to the center.

Your Signature

Date * required

Thank you! We’ll be in touch.

1186 County Road 126
New Albany, MS 38652

662-316-7296

hall.sonya69@gmail.com

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