<p> NADEAU’S PLAYSCHOOL ENROLLMENT FORM</p><p>Child’s Name: ______Date of Birth: ______</p><p>Date of Admission: ______Date of Termination: ______</p><p>Hours of pick-up and drop off of your child: ______</p><p>Home Address: ______</p><p>Parent/Guardian Name: ______Home Phone: ______</p><p>Address: ______Cell Phone: ______</p><p>Employed at: ______Work Phone: ______</p><p>Parent/Guardian Name: ______Home Phone: ______</p><p>Address: ______Cell Phone: ______</p><p>Employed at: ______Work Phone: ______</p><p>Parent the child resides with: ______</p><p>Child’s Doctor: ______Phone #: ______</p><p>Child’s Dentist: ______Phone #: ______</p><p>*Emergency Contacts: 1.______Phone #: ______(Other than parent/guardians)</p><p>2.______Phone #: ______</p><p>Names and ages of other children living at home: ______</p><p>Names of persons authorized to take child from center: (Name, Address and Telephone Number)</p><p>1. ______2. ______3. ______Please describe your child’s: Height _____Weight ____ Eye Color ____Hair Color: _____</p><p>*Two alternate contacts are required by state regulations prior to enrollment</p><p>Birthmarks or other distinguishing physical characteristics: ______</p><p>Does your child wear: Glasses_____ if so please describe them: ______Dental Braces_____ Special clothing or footwear______Prosthesis ______</p><p>Does your child have any allergies? ______if so to what______</p><p>Does your child have any special dietary requirements? ______If yes, please explain______</p><p>Does your child take daily medications? _____ If so, what are they and what are they for______</p><p>Any special family situations that will help us to know your child (i.e. new baby, di- vorce etc.) ______</p><p>Has your child been in childcare before? ____ Where? ______</p><p>Can we contact your previous childcare? ______</p><p>How does your child handle separation from Parents? ______</p><p>What activities, situations or food does your child especially like? ______</p><p>What activities, situation or food does your child especially dislike? ______</p><p>How does your child display anger? ______</p><p>How does your child display fear? ______Does your child have security items (blanket or animals etc.)? ______</p><p>Has your child ever had a negative experience in a childcare setting? ____If yes, please explain: ______</p><p>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? ______</p><p>What does a typical day/schedule look like for your child? ______</p><p>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.</p><p>___I give permission for my child to use all of the play equipment and participate in all the activities of the child care center.</p><p>___I give permission for my child to participate in field trips and excursions, under proper supervision.</p><p>___I give permission for my child to take walks with the childcare staff.</p><p>___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.</p><p>___ 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.</p><p>___I give permission for the staff to administer the sunscreen and bug spray I have pro- vided after 6 months of age.</p><p>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.</p><p>______Parent Signature Date</p><p>______Parent Signature Date</p><p>______Director Signature Date</p><p>*Please make sure to provide the Director with any updated copies of your child’s im- munization records.</p>