Busy Day Family Daycare Enrollment form
_______________________________________________________


Child's Name:__________________________________

Child's Date Of Birth:____________________________
home tel#_____________

Father's Name:____________________________

Mother's Name:_______________________________

Mother's Address:______________________________________

Mother's Employer and address:_______________________
Telephone:________

Father's address(if differant):______________________
Telephone:___________

Father's Employer and address:________________________
Telephone:___________

________________________________________________________________



Days of Care:(circle) M     TU   W   TH   F


Hours of Care(between 6:30 am and 5:30 pm)______________________ 

 

  EMERGENCY INFORMATION
  

PERSON'S TO CALL IN AN EMERGENCY:

Name:_________________________

Address:____________________

Telephone:_____________________
relationship to child_________________



Name:_____________________

Address:___________________

Telephone:__________________
relationship to child______________________




CHILD MAY BE RELEASED TO:

Name:_______________________

Address:__________________________

Telephone:________________________relationship to child_______________



Name:_____________________________

Address:________________________

Telephone:_________________________relationship to child_________________



PHYSICIANS NAME:___________________________

Telephone:____________________________

Any allergies child may have:__________________________



(Transportation permission attatched)

_______________________________________________________



The provisions outlined on this form have been worked out in consultation with me and have my approval.

Signature of Parent or Guardian:______________________Date:____________

Signature of Parent or Guardian:________________________Date:_______________













 
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