Enrollment Application

Your Enrollment Application

ENROLLMENT APPLICATION form

FTCTTC-EDUCATION

BABIES ON UP!

ENROLLMENT APPLICATION

ENTRANCE DATE

WITHDRAWAL DATE

CHILD’S NAME

GENDER

AGE

DATE OF BIRTH

HOME ADDRESS (STREET)

CITY

STATE

ZIP CODE

PHONE NUMBER (HOME/CELL)

RELATIONSHIP TO CHILD

DOES THIS CHILD LIVE IN THE SAME HOME AS THE PARENT/GUARDIAN LISTED?

YES

PARENT(S)/GUARDIAN(S)PLACE OF EMPLOYMENT

WORK PHONE

EMPLOYERS STREET ADDRESS

CITY

STATE

ZIP CODE

CHILDCARE SCHEDULE NEEDED

MONDAY: FROM

TUESDAY:FROM

WEDNESDAY:FROM

THURSDAY:FROM

FRIDAY:FROM

MEAL SATISFACTORY

PLEASE CIRCLE YOUR CHILD’S MEAL NEEDS FROM FTCTTC-EDUCATION

MY CHILD NEEDS

BREAKFAST

LUNCH

DINNER

ALL THREE MEALS

MY CHILD’S FAVORITE FOODS

MY CHILD’S LEAST FAVORITE FOODS

MY CHILD IS ALLERGIC TO OR CANNOT HAVE THESE TYPES OF FOODS

SPECIAL NOTE

* MEALS WILL BE PROVIDED TO CHILDREN BY FTCTTC. YOU ARE NOT REQUIRED TO BRING MEALS UNLESS YOUR CHILD(REN) HAVE SPECIALS MEAL NEEDS.

EMERGENCY CONTACT INFORMATION

*YOU MUST PROVIDE AT LEAST TWO EMERGENCY CONTACTS

NAME

PHONE NUMBER

ADDRESS

RELATIONSHIP TO CHILD

HEALTH CARE NEEDS

List any allergies and the symptoms and type of response required for allergic reactions

List any health care needs or concerns, symptoms of and type of response for these health care needs or concerns

List any particular fears or unique behavior characteristics the child has

List any types of medication taken for health care needs

Share any other information that has a direct bearing on assuring safe medical treatment for your child

EMERGENCY HEALTH CARE INFORMATION

Name of health care professional

Office Phone

Hospital preference

Phone

I, as the parent/guardian, authorize the center to obtain medical attention for my child in an emergency.

Should my child suffer an injury or illness while in the care of FTCTTC-EDUCATION and FTCTTC EDUCATION is unable to contact me(parent(s)/guardian(s)) immediately, it shall be authorized to secure such medical attention and care for the child as may be necessary. The parent(s)/guardian(s) shall assume responsibility
for payment for services.

Before any medication is dispensed to my child, I will provide a written authorization, which includes: date; name of child; name of medication; prescription number; if any; dosages; date and time of day medication is to be given. Medicine will be in the original container with my child's name marked on
it.

My child will not be allowed to enter or leave the facility without being escorted by the parent(s)/guardian(s), person authorized by parent(s)/guardian(s), or facility personnel

I acknowledge it is my responsibility to keep my child's records current to reflect any significant changes as they occur, e.g., telephone numbers, work location, emergency contacts, child's physician, child's health status, infant feeding plans and immunization records, etc.

FTCTTC agrees to keep me informed of any incidents, including illnesses, injuries, adverse reactions to medications, etc., which include my child.

FTCTTC agrees to obtain written authorization from me before my child participates in routine transportation, field trips, special activities away from the facility, and water-related activities occurring in water that is more than two (2) feet deep.

I authorize the child care facility to obtain emergency medical care for my child when I am not available.

I have received a copy and agree to abide by the policies and procedures for FTCTTC-EDUCATION

I understand that the facility will advise me of my child's progress and issues relating to my child's care as well as any individual practices concerning my child's special needs. I also understand that my participation is encouraged in facility activities.

* BY SIGNING THIS AGREEMENT I UNDERSTAND AND ACCEPT THE TERMS AND I AM AWARE THAT FAILURE TO ABIDE BY THIS AGREEMENT, MY
CHILD(REN) WILL IMMEDIATELY BE REMOVED FROM THE PROGRAM AND FURTHER ACTION WILL BE TAKEN IN ATTEMPT TO RECEIVE PAYMENT.

PRINT NAME

PARENT/GUARDIAN’S SIGNATURE

DATE SIGNED