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Application for Enrollment

Family Information

Child will be released only to the parents/guardians listed above. The child can also be released to the following individuals, as authorized by the person who signs this application. In the event of an emergency, if the parents/guardians cannot be reached, the facility has permission to contact the following individuals.

Health Care Needs
For any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services, a medical action plan shall be attached to the application. The medical action plan must be completed by the child’s parent or health care professional. Is there a Medical action plan attached?
(Medical action plan must be updated on an annual basis and when changes to the plan occur)
Emergency Medical Care Information

I, as the parent/guardian, authorize the center to obtain medical attention for my child in an emergency.

Thank you for applying.

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