Enroll - Little Sunshine Childcare Center

Date Began Care:

Child's Name

Child's Birthday

Physical Address

Home Phone:

Cell Phone:

Parent/Guardian Information

Alternative Emergency Contacts

Who is authorized to pick up your child other than yourself?

Medical Information

General Information

Please help me get to know your child better:

Permission: (a check indicates permission is granted)

In an emergency, the child care provider (or substitute) has my permission to call an ambulance or to take My child to a physician, hospital, or dentist at my expense.

I do not wish for my child to have medical treatment

My child may be taken on field trips or excursions by bus or private automobile under supervision.

My child may be photographed for publicity or news purposes.

My child may not be photographed for publicity or news purposes.

Signature of parent or guardian

Today's Date

Signature of parent or guardian

Today's Date

I have received and read polices/procedures

I have received and read discipline policies

I have received and read my contract

I have provided my child’s immunization records, verifying he/she is up to date

I understand my provider is a mandatory reporter