Child Enrollment Information - Sunflower Child Development Center

Child Information

Name

Date of Birth

Gender

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Child lives primarily with:

Mom
Dad
Mom & Dad
Guardian

PARENT/GUARDIAN INFORMATION

Name:

Relationship to Child:

Is your address the same as child's?

Yes
No

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Cell #

Home #

Work #

Email (personal):

Email (work):

Place of work:

City:

PARENT/GUARDIAN INFORMATION

Name:

Relationship to Child:

Is your address the same as child's?

Yes
No

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Cell #

Home #

Work #

Email (personal):

Email (work):

Place of work:

City:

Emergency Contact 1

Name

Relationship to Child:

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Cell #

Home #

Work #

Emergency Contact 2

Name

Relationship to Child:

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Cell #

Home #

Work #

Emergency Contact 3

Name

Relationship to Child:

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Cell #

Home #

Work #

AUTHORIZED TO PICK UP

Include Emergency contacts

Authorized Pickup People

Name

Phone #

Relationship to child:

Individuals NOT authorized to pick up:

(with copy of court order if applicable)

Individuals NOT authorized to pick up:

Name

Phone #

Relationship to child:

Physician

Physician's Name:

Clinic:

Phone #

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Does your child have health insurance?

Yes
No

Company Name

Dentist

Dentist's Name:

Clinic:

Phone #

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Does your child have dental insurance?

Yes
No

Company Name

Preferred Hospital:

Phone #

Sunflower Child Development Center is authorized to obtain EMERGENCY MEDICAL or EMERGENCY DENTAL care even if unable to immediately make contact with a parent/guardian.

Yes
No

Consent & Release

Consent & Release For The Following Items:

Walking Field Trip Decorah Public Library, Miller Park, ect.
Field Trip utilizing Northeast Iowa Public Transit
Diaper Cream I will provide diaper cream to be used as needed (age appropriate)
Sunscreen Application I will provide sunscreen to be applied twice daily for outdoor play
Bug Repellent I will provide bug repellent to be applied twice daily for outdoor play
Media Release My child may be photographed for purpose of publicity or advertisement & shared with other families also enrolled at Sunflower
DECLINE Media Release Do not photograph my child while in child care

Special needs for transportation:

Signatures

Information provided will be reviewed yearly. Please notify Administration of any changes as they occur.

Year 1

Signature of Parent/Guardian *

Use your mouse, track-pad, or phone screen to sign this document above.

Date

Year 2:

Signature of Parent/Guardian

Date

Year 3:

Signature of Parent/Guardian

Date