Nadeau S Playschool

NADEAU’S PLAYSCHOOL ENROLLMENT FORM

Child’s Name: ______Date of Birth: ______

Date of Admission: ______Date of Termination: ______

Hours of pick-up and drop off of your child: ______

Home Address: ______

Parent/Guardian Name: ______Home Phone: ______

Address: ______Cell Phone: ______

Employed at: ______Work Phone: ______

Parent/Guardian Name: ______Home Phone: ______

Address: ______Cell Phone: ______

Employed at: ______Work Phone: ______

Parent the child resides with: ______

Child’s Doctor: ______Phone #: ______

Child’s Dentist: ______Phone #: ______

*Emergency Contacts: 1.______Phone #: ______(Other than parent/guardians)

2.______Phone #: ______

Names and ages of other children living at home: ______

Names of persons authorized to take child from center: (Name, Address and Telephone Number)

1. ______2. ______3. ______Please describe your child’s: Height _____Weight ____ Eye Color ____Hair Color: _____

*Two alternate contacts are required by state regulations prior to enrollment

Birthmarks or other distinguishing physical characteristics: ______

Does your child wear: Glasses_____ if so please describe them: ______Dental Braces_____ Special clothing or footwear______Prosthesis ______

Does your child have any allergies? ______if so to what______

Does your child have any special dietary requirements? ______If yes, please explain______

Does your child take daily medications? _____ If so, what are they and what are they for______

Any special family situations that will help us to know your child (i.e. new baby, di- vorce etc.) ______

Has your child been in childcare before? ____ Where? ______

Can we contact your previous childcare? ______

How does your child handle separation from Parents? ______

What activities, situations or food does your child especially like? ______

What activities, situation or food does your child especially dislike? ______

How does your child display anger? ______

How does your child display fear? ______Does your child have security items (blanket or animals etc.)? ______

Has your child ever had a negative experience in a childcare setting? ____If yes, please explain: ______

Is your child toilet trained? ______In training? ______In diapers? ______Does your child nap at home? _____for how long? ____ in a crib or a bed? ______Alone or with others? ______Does your child sleep all night? ______

What does a typical day/schedule look like for your child? ______

Please use the remaining space to tell us anything else you think we should know about your child: ______I give permission to authorize emergency medical care and associated transporta- tion.

___I give permission for my child to use all of the play equipment and participate in all the activities of the child care center.

___I give permission for my child to participate in field trips and excursions, under proper supervision.

___I give permission for my child to take walks with the childcare staff.

___I give permission for my child to be included in picture taking and video filming. This is for in center use only, unless otherwise authorized.

___ I give permission for my child’s photo to be posted on the Nadeau’s Playschool Facebook page. No names or ages will be used wench posting photos. ___I give permission for the staff to use diaper cream I have provided for my child.

___I give permission for the staff to administer the sunscreen and bug spray I have provided after 6 months of age.

Should there be a change in this permission agreement, I will notify the child care staff and they will make the changes in the file.

______Parent Signature Date

______Director Signature Date

*Please make sure to provide the Director with any updated copies of your child’s im- munization records.