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Corinne's Child Care Application

www.corinnesdaycare.com
Email: nobody@corinnesdaycare.com
Phone: (000) 000-0000
Child's First Name:
Child's Last Name:
Child's Date of Birth:
School (if child is school-age):
Mother's First Name:
Father's First Name:
Street Address:
City:
E-mail:


Contact Information

  
Home Phone:
Mother's Work Phone:
Mother's Cell Phone:
Mother's Employer:
Father's Work Phone:
Father's Cell Phone:
Father's Employer:

1st Emergency Contact

 
Name:
Relationship:
Phone:


2nd Emergency Contact

  
Name:
Relationship:
Phone:
Is there any particular care
that the child requires?
First Personal Reference for Parents:
  
Name:
Relationship:
Phone:
2nd Personal Reference for Parents:
 
Name:
Relationship:
Phone:

Is there any other information I
should have regarding your family or child?
Child's Physician:
Physician's Phone:
Child's Dentist
Dentist's Phone:
Child's Favorite Toy:
If you answer "yes" to any of the questions below, please
place additional information at the bottom of this form.
Does the Child have any allergies?
 Yes No
Does the child have disabilities?
 Yes No
Does the child have any
conditions such as asthma?
 Yes No
Does the child have social
or developmental problems?
 Yes No
I hereby give permission to secure emergency medical care for the child named in this application if neither I nor the child's doctor can be contacted immediately.
Name:
Signature:
Date:

Mail to:

Corinne's Day Care
6408 Knollwood Rd
Skokie, Illinois 42204