Please print legibly. Complete one form for every child to be placed on the waiting list.
--Select Time --Full-timePart-Time
MondayTuesdayWednesdayThursdayFriday
--Select Gender --MaleFemale
--Select Child lives with --MotherFatherBoth parents
Please indicate and comment on the following health areas and provide any additional special instructions for the provision of care for your child
Is your child immunized against communicable illness?
--Select--YesNo
In Case of Illness or Injury I hereby give permission for the center staff or their representative to call an ambulance for transportation to the nearest hospital if needed. I understand that all costs incurred are the responsibility of the parent /guardian.
Parent/Guardian Signature Date