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"*" indicates required fields

Contact Information

Child's Full Name:*

Child's Nickname:*

Birthdate:

Date of Enrolment:

Home Phone:

Address:

Mother's Information

Mother's Full Name:

Mother's Home Phone:

Mother's Address:

Mother's Employer

Mother's Employer:

Mother's Occupation:

Hours at Work:

Days at Work:

Work Phone:

Cell Phone:

Employer's Address:

Untitled

Father's Information

Father's Full Name:

Father's Home Phone:

Father's Address:

Father's Employer

Father's Employer:

Father's Occupation:

Hours at Work:

Days at Work:

Work Phone:

Cell Phone:

Employer's Address:

Fill out only if applicable

Parent/Guardian with legal custody:

Do you have a decree on file?:

Parents are:

Primary Emergency Contact

Full Name:

Relationship to child:

Address:

Phone:

Secondary Emergency Contact

Full Name:

Relationship to child:

Address:

Phone:

Person(s) authorized to pick up my child (Besides parents/guardians or emergency contacts)

Person #1:

Person #2:

Person #1:

Daycare references

Has your child ever been in daycare before?:

If so, why did you leave?:

Name of previous provider:

Phone number of previous provider:

Consent to Emergency First Aid & Transportation

I hereby give my permission that my child, may be given emergency treatment by Creative All Stars Childcare I also give permission for my child to be transported by car or ambulance to an emergency center for treatment.

yes

Consent to Medical Care & Treatment

In the event that I cannot be contacted immediately, medical or surgical treatment can be administered to my child in the case of an accident or emergency, as prescribed by a treating physician.

yes

Consent to Photograph

yes

Creative All Stars Childcare will not be responsible for paying for my child's healthcare

Child's Physician:

Phone:

Preferred Hospital:

Phone:

Insurance Company:

Policy Number:

Regular Medications:

Blood Type:

Medicine Allergic to

Food Allergies:

Other Allergies:

Special Health Conditions:

Carecard Number:

Creative All Stars Childcare will not be responsible for paying for my child's healthcare

Number of days per week childcare is needed:

Days of week care is needed:

What time will you bring your child to daycare?:

What time will you pick-up your child?:

For Out of School Care

What School does your child attend?

Email*

Comments

Agreement

I understand that this is a legally binding document, and have read it and understand it.

yes

Phone

This field is for validation purposes and should be left unchanged.

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registration

Contact Information

Mother's Information

Mother's Employer

Father's Information

Father's Employer

Fill out only if applicable

Primary Emergency Contact

Secondary Emergency Contact

Person(s) authorized to pick up my child (Besides parents/guardians or emergency contacts)

Daycare references

Consent to Emergency First Aid & Transportation

Consent to Medical Care & Treatment

Consent to Photograph

Creative All Stars Childcare will not be responsible for paying for my child's healthcare

Creative All Stars Childcare will not be responsible for paying for my child's healthcare

For Out of School Care

Agreement

Direction

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Schedule

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