Enrollment Form

Father's Name
Father's address if different from child's
Street Address Address Line 2 City State ZIP Code
Father's telephone number
Father's Place of Employment
Father's Address of Employment
Street Address Address Line 2 City State ZIP Code
Father's Business Telephone Number
Untitled
Mother's Name
Mother's address if different from child's
Street Address Address Line 2 City State ZIP Code
Mothers's telephone number
Mother's Place of Employment
Mother's Address of Employment
Street Address Address Line 2 City State ZIP Code
Mother's Business Telephone Number

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)
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 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
- No
IF Yes, Please Specify
Special accommodation(s) may be required to most effectively meet my child's needs while at this center
- Yes
- No
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
- No
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*
Phone
This field is for validation purposes and should be left unchanged.