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CHILDRENS SERVICES
PAYMENTS
DONATIONS
Days Requested
(to be completed by family upon submission)
MTWTF
MWF
TTH
Before Care
After Care
Admission Application for Children's Services
Date of Application
Date Enrollment is Needed
Child's Full Name
Name preferred by child
Social Security #
Child's Birthdate
Allergies/Special Needs
Guardian Information
Primary Contact
Guardian Name
Relationship to Child
Phone
Email
Home Address
Street
City
State
Zip
Employment
Employer
Work Phone
Employer Address
Work Hours
Secondary Contact
Guardian Name
Relationship to Child
Phone
Email
Home Address
Street
City
State
Zip
Employment
Employer
Work Phone
Employer Address
Work Hours
Emergency Information
(Contact if parents cannot be reached)
1.
Name
Work Phone
Home Phone
Address
2.
Name
Work Phone
Home Phone
Address
3.
Name
Work Phone
Home Phone
Address
Transportation Plan
Person who will bring child on most days:
Person who will pick up child on most days:
Other Than Parent/Guardian, Those Authorized to Pick Up Child
1.
Name
Relationship
2.
Name
Relationship
3.
Name
Relationship
Date of pre-placement visit:
English
English
English