Child Enrollment Form

Participant Info

Child’s Name
Name you prefer your child to be called
Please Check One

FT PT Droipn B/A School
Full Legal Name(s) of Parent or Guardian
Relationship
Home Address
Streeet
City
Zip Code
Home Phone
Work Phone
Birth Date
Family Dentist
Family Physician
Clinic
Telephone
Hospital
Telephone
Last Visit to Doctor
Child's Height
Child's Weight

Does the child have any food, medication or environmental allergies


Please Check if any one of the following conditions exist

Asthma

Heart Condition

Hearing Impairment

Behavioral Issues

Diabetes

Seizure Disorder

Frequent Earaches

Vision Impairment

Other Conditions (Please Specify)

Please explain all checked items

Is the child under current medical treatment


Are there medications that the child takes daily

Describe any limitation your child may have for participation in an early childhood program

Is there a health care plan for your child


Mother/Guardian

Name
Home Phone
Home Address
Cell
Employer
Work Phone
Employer Address
Fax
Email Address


Father/Guardian

Name
Home Phone
Home Address
Cell
Employer
Work Phone
Employer Address
Fax
Email Address


Additional Approved Adults

Approved Adult One
Approved Adult Two
Name
Relationship
Name
Relationship
Home Phone
Cell
Home Phone
Cell
Employer
Workphone
Employer
Workphone