Application

Child Enrollment and Authorization
Child’s Name _________________________            Enrollment Date ______________________________
Child’s Nickname _____________ Birth Date _____________Preferred Pronoun ________________
ALLERGY ALERT:  Does child have allergies? YES NO  

If yes, list all allergies:

SPECIAL DIET:
Parent or Guardian Contact Information
Name (first, last) Relationship
Street Address City Zip
E-mail Home phone
Employer/Work hours/Work phone Cell phone
Name (first, last) Relationship
Street Address City Zip
E-mail Home phone
Employer/Work hours/Work phone Cell phone
Required Emergency Contacts- person other than parent or guardian who is authorized to pick up child
Name (first, last) Phone Relationship
Name (first, last) Phone Relationship
Medical/Dental Contact Information
Insurance Provider Member no. Group no.
Policy Holder Name Policy Holder Date of Birth
Primary Physician Name Phone
Dental Provider Name Phone
Parent or Guardian Authorization
Please list any restrictions to permission of the following:
My child may be photographed for publicity or news purposes    On-site      Off-site
My child may be given non-prescribed medication as indicated on the container.  This may include sunscreen, children’s pain reliever,  antibacterial first aid cream, and diapering ointment.  Syrup of ipecac may be administered if deemed necessary by the poison control operator.    The child’s parent or guardian will be contacted prior to administering non-prescription pain relievers.  Prescription medications must be current and a permission slip is required per each medication.
In an emergency, Liz Gustafson  has my permission to call an ambulance, or take my child to any available physician or hospital at my expense to obtain medical treatment.  In most emergencies, 911 is called and the child is transported to the nearest hospital and treated by the on-call physician.  The parent or guardian of the child is notified as soon as possible.
My child may go on walking field trips with Liz Gustafson.  This may include local parks and playgrounds, community  destinations and other places of interest.  Liz will inform me of the proposed destination prior to the field trip whenever possible . Parent/Guardian Signature Date

Child Information

Child General Information-

please include all information that will assist us in providing quality care for your child
Has your child ever been in child care?          If so, what kind?
Likes and Dislikes
Eating Habits and Schedule
Play/Favorite Toys & Activities
Fears
How do you comfort your child?  
Special Words and their Meanings
Does your child chew unusual things such as pencils, chalk, cribs, window ledges, paint chips, plaster, or hair?

 Yes  No If yes, please provide details:
Is your child toilet trained? Yes No

If yes, how much assistance does he/she need in the bathroom (undressing, hand washing, getting off the potty, etc.)?
Sleeping Habits and Schedule
What does your child use at naptime?    blanket pacifier stuffed animal/toy other
Child Medical Information- Include instructions for providing best possible care in regard to stated conditions.  Tell us if any of the medical conditions restrict your child’s activities.
Does your child have allergies? Yes  No Has your child had chickenpox?   Yes         No
Allergies
Chronic Illnesses
Current Medications
Other Conditions
Other Children in Home
Name (first, last) Nickname Age Sex
Name (first, last) Nickname Age Sex
Name (first, last) Nickname Age Sex
Parent/Guardian Signature Date
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