Forms

Enrollment Form

Medical Release form

Transportation Permission Form

ENROLLMENT FORM FOR SUE’S HOME AWAY FROM HOME FAMILY CHILD CARE

Child's Full Name:__________________________Nickname:_____________

Birth date:_____________________________

Address:_______________________________Home Phone:_________________

Mother's Full Name:________________________

Address:__________________________Home Phone:______________

Mother's Occupation:______________Employer

Name:_________________________________

Work Address:_________________________________________Hours at work:____ to ____.

Work Phone:_________ ext.____ Pager or Cell #___________

Father's Full Name:______________________

Home Phone:________________Address:_________________________________________

Occupation:______________Employer Name:__________________________

Work Address:_________________________Hours at work:_____ to ______

Work Phone:__________ ext____ Pager or Cell #__________

Both parents please initial below.............

Home phone may be given to my other clients? YES_______NO________

Work phone may be given to my other clients? YES_______NO________

If parent needs to be contacted, which parent called first? MOM or DAD

(Fill out only if applicable)

Parent/Guardian with legal custody:_______________

Parents are: Married /Divorced / Separated /Widowed /Single

Primary Emergency Contact other than parents/guardian):______________________

Home Phone:_________________ Work Phone:_________________

Emergency contact address____________________________

Relationship to Child:______________________

Secondary Emergency Contact other than parents/guardian):___________________________

Home Phone:_____________ Work Phone:_____________

Second Emergency contact address:___________________

Person(s) authorized to pick up my child Besides parents/guardians or emergency pick ups):___________________________________________________________

(With prior notice from parent/guardian, and picture ID upon arrival)

Daycare References:

Has your child ever been in daycare before?_________

If so, why did you leave?_____________________________________________________

Name of Previous Provider:______________Phone number of Previous Provider:________

Medical Information

Physician’s Name__________________________ Phone___________________________

Name of Clinic ____________________________________ 

If unavailable, another physician may treat my child   yes ________        No___________

Medical Insurance Company ______________________________ policy No. ____________

Dentists Name _____________________________  phone ____________________________

If unavailable, another Dentist may treat my child ___________________________________

Overview

Number of days per week child care is needed:___

Days of week care is needed:___________________________________I will bring my child to day care at:___ AM/___PM

I will pick up my child:___ AM___PM____Weekly fee:_____Late fee:_____

Comments: 

Signatures:

Provider:______________________Date:_____________

Parent/Guardian:______________________Date:______________________________

Parent/Guardian:______________________Date:______________________________

(I understand that this is a legally binding document, and have read it and understand it)

In case of medical/surgical emergency, we hereby authorize all necessary tests, procedures and/or treatment for our child _____________________

Clinic Number ___________________

When we are not available.  We authorize _________________________

To seek such medical care.

We assume responsibility for all costs of emergency transportation and care.

Date _____________    Signed ______________________________

                                                         (parent or guardian of child)

Date ______________   Signed _______________________________

                                                                   Notary Public

Transportation Permission Form

I, _________________________________ (parents name) give Sue Conant

Permission to transport my child/children ___________________________.

I understand that all children wear a seat belt or are placed in a car seat

Depending on their age.  I am willing to leave a child’s car seat for use on

field trips, if needed. Children will be transported by a licensed driver with

proper auto insurance.  I understand that Sue will inform parents of 

scheduled field trips in advance.

I, _____________________________ (parents name) would like to be notified by phone prior to any unscheduled trips.  _____yes ____no

If I can’t be reached by phone, I would like Sue to:

_______wait until I can be reached

_______leave a message for me about the trip.

___________________________________________parents signature

_____________________ date