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Childcare Application
Fill out the form below to apply
Child's Name
*
Reason for requesting daycare
Sex
*
Male
Female
Address/City/Zip
Age
*
8
9
10
11
12
13
14
Phone
*
Birthdate
*
Email
*
Mother's Name
*
Father's Name
*
Mother's Birthday
Father's Birthday
Mother's SSN
Father's SSN
Ages of other children not enrolled in daycare
Income Source
*
(Employment name, address & #, Public Assistance, Social Security, Other)
Public Assistance
*
None
TANF
SNAP
Both SNAP & TANF
Family Size
*
Amount Per Month
*
Family Doctor Name
*
Family Doctor Phone
*
Family Doctor Address
Has your child had any serious illness requiring hospitalization?
*
Yes
No
What?
When?
Where?
Is your child taking any medication?
*
Yes
No
What Medication?
Is your child allergic to any medication?
*
Yes
No
What medication are they allergic to?
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Phone
Emergency Contact Address
Characteristic behavior
calm
cheerful
whining
excitable
easily angered
crying
happy
negative
cooperative
Fear (describe)
How is your child disciplined at home?
Social behavior
shy
friendly
fearful
aggressive
What previous group experienced has child had?
Are there any specific problems you would like to talk over?
Is your child accustomed to taking nap?
Yes
No
Does your child have any allergies to food or animals?
Yes
No
Does your child ever use a bottle?
Yes
No
Comment
Submit
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