CHILD’ S PREADMISSION RECORD – Kids of Character Early Learning Center, LLC

CHILD' S PREADMISSION RECORD

Step 1 of 2

This section is to be completed by the child's parent or guardian. This form muat be kept in the child's file in the Child Care Facility.

Child's Name:(Required)

Name Child is Known By:(Required)

Child's birthdate:(Required)

Child's home address:(Required)

Name(s) of parent(s)/guardian(s):(Required)

Home telephone number:(Required)

Address of parent(s)/guardian(s):(Required)

Mother's employer:(Required)

Father's employer:(Required)

Mother's Email Address:(Required)

Father's Email Address:

Employer's address:(Required)

Employer's address:

Employer's telephone number:(Required)

Employer's telephone number:

List telephone numbers such as beeper, cellular phone, etc.

Instructions regarding how parent/guardian may be reached in an emergency:

Person(s) to be contacted in an emergency if parent(s)/guardian(s) cannot be reached:

Name(Required)

Relationship to child(Required)

Address..(Required)

Telephone number(Required)

Name of child's doctor:

Address:

Telephone number:

Emergency Authorization: I give permission for the child care facility to obtain emergency medical treatment, including emergency transportation, for my child if I cannot be reached immediately. I agree to be responsible for any emergency medical expenses incurred. (If parent/guardian refuses to sign, instructions must be attached stating what procedure the facility is to follow in an emergency.)

Date

Signature(Required)

Form not valid without signature of child's parent/guardian
Page one of two-form not valld without second page

Child's Preadmission Record (continued) - page two of two-form not valid without first page

Describe any special needs or Instructions below:

Person(s) the child may be released to:

Name(Required)

Relationship to child(Required)

Address(Required)

Telephone number(Required)

I understand that the Department of Human Resources does not Inspect activities away from the child care facility. The licensee of the child care faollity assumes full responsibility for such activities.

Date

Signature

I give permission for my child to participate in:

Activities away from the facility:(Required)

Yes

Date

Signature of parent/guardian(Required)

Transportation provided by the facility:(Required)

Yes

Date

Signature of parent/guardian(Required)

Swimming/wading activities provided by the facility:(Required)

Yes

Date

Signature of parent/guardian(Required)

Form not valid without signature of child's parent/guardian in each space Indicated above.

Section Break

This section is to be completed by the facility's staff.

Child's first day of attendance:(Required)

Child's withdrawal date:(Required)

This child meets the definition of homelessness according to the McKinney-Vento Homeless Assistance A

Additional information may be attached.