Enrollment FormEnrollment FormStep 1 of 520%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 AgeSex* Male Female Prefer not to discloseHome Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Telephone NumberEmail Address Father's NameFather's address if different from child's Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Father's telephone numberFather's Place of EmploymentFather's Address of Employment Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Father's Business Telephone NumberUntitledMother's NameMother's address if different from child's Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mothers's telephone numberMother's Place of EmploymentMother's Address of Employment Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mother's Business Telephone NumberChild's Living Arrangements Both Parents Father Mother OtherIf Other Please SpecifyChild's Legal Guardian(s) Both Parents Father Mother OtherIf Other Please SpecifyThe 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)Name and Address (include complete street address, city, state and zip code)Name and Address (include complete street address, city, state and zip code)Name and Address (include complete street address, city, state and zip code)Persons to contact in case of an emergency when parents cannot be reachedEmergency Contact Name 1Telephone NumberEmergency Contact Name 2Telephone NumberEmergency Contact Name 3Telephone NumberName 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 NumberMy child has special need(s) Yes NoIF Yes, Please SpecifySpecial accommodation(s) may be required to most effectively meet my child's needs while at this center Yes NoIF Yes, Please SpecifyMy 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 NoIF Yes, Please SpecifyEMERGENCY 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*PhoneThis field is for validation purposes and should be left unchanged.Δ