Corinne's Daycare Application

Print Application ~ JaybirdsWeb
Child Care Application You can either submit your child care application online, or you can print and mail in your application, click here for the print version.
Child's First Name:
Child's Last Name:
Child's Date of Birth:
School (if child is school-age):
Mother's Name:
Father's 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
Additional information:

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. My submittal of this electronic form acts in lieu of a signature and is binding to this contract.

Name:

Signature:

Date:

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Child Care Application

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