CreativeKidz Daycare and Pre-school’s Application Form

Application

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PRE VISIT DATE

DATE OF ADMISSION

CHILDS NAME

First

Last

CHILD'S ADDRESS

Address Line 1

Address Line 2

City

State

Zip Code

MOTHER'S NAME

EMPLOYMENT

HOME #

WORK#

CELL#

FATHER'S NAME

EMPLOYMENT

HOME #

WORK#

CELL#

TRANSPORTATION

TO ENSURE THE SAFETY OF YOUR CHILD, PLEASE LIST OTHER ADULTS TO WHOM YOUR CHILD MAY BE RELEASED.

ALLERGIES

FOOD ALLERGIES

OTHER ALLERGIES

AGE AND Layout

EMERGENCY CONTACT

NAME OF PERSON AUTHORIZED TO ACT FOR PARENT IN AN EMERGENCY

Address

Address Line 1

Address Line 2

City

State

Zip Code

NAME OF PHYSICIAN

PHONE

SCHOOL AGE ONLY

WHAT SCHOOL DOES CHILD ATTEND

WHAT GRADE IS CHILD IN

CREATIVE KIDZ PROVIDING TRANSPORTATION TO AND FROM SCHOOL?

TODDLER AND PRESCHOOL ONLY

IS YOUR CHILD POTTY TRAINED?

WHAT DOES YOU CHILD SAY WHEN THEY NEED TO USE THE RESTROOM?

CAN USE RESTROOM BY HIMSELF?

EMERGENCY EVACUATION ONLY

I HEREBY AUTHORIZE THE CENTER TO PROVIDE EMERGENCY MEDICAL CARE OR TRANSPORTATION.

DHS LICENSING

I HAVE RECEIVED A SUMMARY OF THE 2022 LICENSING RULES FOR CHILDCARE AGENCIES. I AM ALSO AWARE THESE ARE ONLINE TO VIEW ANYTIME AS WELL.

SIGNATURE OF PARENT/ DATE

Clear Signature