Enrollment Form - Briarcliff Child Care Centers

Entrance Date

MM slash DD slash YYYY

Withdrawal Date

MM slash DD slash YYYY

Child's Name*

Date of Birth

MM slash DD slash YYYY

Age

Sex*

Male

Female

Prefer not to disclose

Home Address*

Street Address Address Line 2 City State ZIP Code

Home Telephone Number

Home Email Address

Father's Name

Father's Telephone Number

Father's address if different from child's

Street Address Address Line 2 City State ZIP Code

Father's Place of Employment

Father's Business Telephone Number

Father's Address of Employment

Street Address Address Line 2 City State ZIP Code

Mother's Name

Mothers's telephone number

Mother's address, if different from child's

Street Address Address Line 2 City State ZIP Code

Mother's Place of Employment

Mother's Business Telephone Number

Mother's Address of Employment

Street Address Address Line 2 City State ZIP Code

Child's Living Arrangements

Both Parents

Father

Mother

Other

If Other, Please Specify

Child's Legal Guardian(s)

Both Parents

Father

Mother

Other

If Other, Please Specify

The child may be released to the person(s) signing this agreement or to the following:

Name and Address (include complete street address, city, state and zip code)

Persons to contact in case of an emergency when parents cannot be reached

Emergency Contact Name 1

Telephone Number

Emergency Contact Name 2

Telephone Number

Emergency Contact Name 3

Telephone Number

Name of public or private school child attends, if any:

Child's Physician or Clinic's Name (Child's Primary Health Source)

Physician/Clinic’s Telephone Number

My child has special need(s)

Yes

IF Yes, Please Specify

Special accommodation(s) may be required to most effectively meet my child's needs while at this center

Yes

IF Yes, Please Specify

My child is currently on medication(s) prescribed for long-term continuous use and/or has the following pre-existing illness, allergies, or health concerns

Yes

IF Yes, Please Specify

EMERGENCY MEDICAL AUTHORIZATION Should {Child\'s Name:3} Date of Birth suffer an injury or illness while in the care of Briarcliff Daycare Center and the facility is unable to contact me/us immediately, it shall be authorized to secure such medical attention and care for the child as may be necessary. I/We agree to keep the facility informed of changes in telephone numbers, etc. where I can be reached. The facility agrees to keep me informed of any incidents requiring professional medical attention involving my child.

Parent/Guardian Name*

Relationship to Child*

Email Address*

Enter Email Confirm Email

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