Child care and preschool center
4700 S. Folsom - Lincoln, NE 402-423-4536
(HKDO)
Train up a child in the
way he should go; even when he is old he will not depart from it.
-Proverbs
22:6
ENROLLMENT APPLICATION
Please complete the form to apply for child care
openings. Before we guarantee your
child’s place, the Enrollment Form, Contract for Child care Services, and
deposit must be received in full.
Full-time Monday Infant Potty Trained
Part-time Tuesday Toddler Additional Siblings
Wednesday Preschool Age Hope Employee
Thursday Preschool Sessions Only
Friday
CHILD’S INFORMATION
Date ___________________
Child’s Name ____________________
Nickname_____________
Address
_________________________Phone ________ Alt _____________
Zip _______________________
Phone # ___________________________
Sex: M F Height _____ Weight _____ Hair Color _______ Eye
Color ____
Social Security # ___/___/____ Race
________ Date of Birth
____________
PARENT/GUARDIAN INFORMATION
Mother’s Name ______________________________ Phone __________________
Employer ___________________________________ Phone
__________________
Best way to reach you
_________________________________________________
Father’s Name _______________________________ Phone
__________________
Employer ___________________________________ Phone
__________________
Best way to reach you
____________________________________________________________
ENROLLMENT
APPLICATION - PAGE 2
OTHER EMERGENCY CONTACTS:
(please list in order of
preference to be contacted)
1. ____________________________________ Phone _______________ Relationship
__________
2. ____________________________________ Phone _______________ Relationship
__________
3. ____________________________________ Phone _______________ Relationship
__________
AUTHORIZED TO PICK UP
CHILD:
1. ____________________________________ Phone _______________Relationship
___________
2. ____________________________________ Phone _______________Relationship
___________
3. ____________________________________ Phone _______________Relationship
___________
MEDICAL INFORMATION:
Please include a copy of child’s immunization records
Doctor’s Name
_________________________ Phone
____________________________________
Hospital preferred
____________________________________________________________________
Childhood illnesses
___________________________________________________________________
Allergies: Food ________________________ Medicines
___________________ Other _____________
Medications:
Current medicines taken: __________________ Dosage: _________________
Other impairments or concerns:
__________________________________________________________
Special care instructions
________________________________________________________________
Is child potty trained? Yes
No
If yes, how does he/she
indicate need to go? ___________________
OTHER:
By signing, I give my authorization to:
Administer appropriate medications at child care.
Seek appropriate emergency medical treatment.
Photograph/video tape child for public display (newspaper, newsletters, etc.)
×__________________________________________________________________________________
Parent signature Date
×__________________________________________________________________________________
Parent signature Date