Childcare enrollment application
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The public child care enrollment application used by families applying to Afternoon Adventure Learning Center.

Also known as: Child care enrollment form; Student enrollment application

Canonical page: https://afternoonadventure.org/resources/documents/childcare-enrollment-application/
Original PDF: https://firebasestorage.googleapis.com/v0/b/afternoon-adventure.firebasestorage.app/o/public%2Fdocuments%2Fchildcare-enrollment-application-main.pdf?alt=media

Document text
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Childcare Enrollment Application
Parents, to protect and promote the health and safety of your child, please supply a complete response to every item on
this form. This information is required by the Mississippi State Department of Health. If the item is not applicable, then
please answer N/A. Please do not leave anything blank.

Child’s Full Name: _ __ __________ ______ (First)
(Middle) (Last)
DOB: Home Address: _____
Home/Cell Phone: ______________________________ __ __ _

Mother/Guardian: Father/Guardian:___ _______
Please check if this parent has primary custody Please check if this parent has primary custody
Please check if court documentation received Please check if court documentation received
*If custody is shared by both parents/guardians, the facility will abide by documentation provided on this
enrollment application.
Place of Employment: Place of Employment:_________ ___

Work Address: Work Address:_____________ ____
___ __________ _________ ____ ___ ___________

Work Phone: Work Phone:_____ _____________

Cell Phone: ______ Cell Phone: ___ ___ __________

E-mail Address: _________________________________ E-mail Address: ________________________
________
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List any special needs your child may have:
____________________________________________________
___________________________________________________________________________ ___
Does your child have any allergies? Please list, including food, if necessary: _________ ______
_____________ _________________________________________________________________
____

Read and INITIAL the appropriate answer to the following items:
I have been informed that this Daycare Center does NOT provide liability insurance for my child: ______Yes ________No
I have been given a copy of and have read the MSDH Regulation Summary for Parents: Yes _______No
I have been given and have read and understand the facility’s Parent Handbook: Yes _______No
Complete 121 Immunization Compliance Form is on file in the facility before the child attends: _______Yes ______No

********PLEASE CONTINUE ON BACK*********
In case of emergency and the Parents/Guardians cannot be reached, please contact:

Developed: 08/01/2015 Revised: 07/09/2020

1. Name:_______________ ____ Phone:______ _____________ Relationship:__________ __________________

Address: _______________________________________ ___ _____

2. Name:_______________ _ Phone:____ ______ _________ Relationship:________ ______________

Address:____________________________________________________________________________ ________

3. Name:_______________ _____ Phone:_____ _ _____ _____ Relationship:________ _ __________

Address: ______________________________________________________________________________ ___

The following people are authorized to pick-up and drop-off my child/children:
1. Name: 2. Name:________________________ 3. Name: __________________________
4. Name:____________________ 5. Name: 6. Name:___________________________
7. Name: 8. Name:________________________ 9. Name: ___________________________
Complete each of the following sections by INITIALING either yes or no:
My child may be photographed at the childcare center: Yes No
My child’s picture may be used in media, i.e., Facebook, newspaper, etc… _________ Yes _______ No
My child may take approved field trips sponsored by the center: Yes No
The center may obtain emergency medical treatment for my child if needed Yes No
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My child is toilet trained Yes No. If no, a consultation between the parent & caregiver is required to be
documented prior to toilet training & kept on file. Date of consultation / / .
My child will eat breakfast/morning snack at the center Yes No. If no, my child will eat BEFORE coming
into the center.

Parent Signature: ______ Date: ___________________

Director Signature: Date:________ ___________

Record to be updated & signed by a parent if NO changes (once a year):
Signature : Date :
Signature : Date :
Signature : Date :

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DIRECTOR USE ONLY: Enrollment date: / / Start Date: / / Withdrawal: / /____

Developed: 08/01/2015 Revised: 07/09/2020