BRIGHT MORNING STAR CHILD CARE APPLICATION FORM

BRIGHT MORNING STAR CHILD CARE
Child Admission Agreement
NAME OF CHILD

First NameLast Name
NICKNAME
Birth Date

MonthDayYear
Date
SEX
Date

MonthDayYear
Date
Type a question

Check the box I no longer enrolled
Home Street Address
Phone #
City
State
Zip
Parents's/Guardian's Name
Phone Number

Area CodePhone Number
Email
example@example.com
Parent's/Guardian's Name
Phone Number

Area CodePhone Number
Work Phone #
EMERGENCY CONTACTS (OTHER THAN PARENTS) AND PERSONS AUTHORIZED TO PICK-UP CHILD (UNLESS THERE IS A COURT ORDER PROHIBITING IT, PARENTS WHOSE NAMES ARE NOT LISTED CAN PICK UP THEIR CHILDREN)

Check if there are no emergency contacts available, other than parents.Check if there are no persons authorized to pick up the child, other than parents.
NAME

First NameLast Name
RELATIONSHIP TO CHILD
ADDRESS
PHONE NUMBER

Area CodePhone Number
NAME

First NameLast Name
RELATIONSHIP TO CHILD
ADDRESS
PHONE NUMBER

Area CodePhone Number
OUT OF AREA/STATE CONTACT NAME
(If available)

Check if there are no out of area/state contacts available.
RELATIONSHIP TO CHILD
ADDRESS
PHONE NUMBER

Area CodePhone Number
In case of an emergency or a serious illness and the parents cannot be reached immediately, I hereby authorize the provider to obtain emergency medical care and/or provide emergency medical transportation for my child.
NAME OF PARENT/GURADIAN
Date

MonthDayYear
Date
I hereby give the provider permission to transport my child in the provider’s vehicle for the following (optional):

To and From SchoolOn Field Trips (with written permission in advance)
Name of Parent/Guardian
Date

MonthDayYear
Date
Name of ParentͬGuardian Date

This form must be reviewed annually by the parent/guardian, and any changes noted.
Date

MonthDayYear
Date
Name

First NameLast Name
Date

MonthDayYear
Date
Name

First NameLast Name
This form is provided for technical assistance purposes only. Providers may use this form if they choose, but are not required to use this form.
Child Health Assessment
There must be a separate health assessment form for each sibling.
Name of Child
Birth Date

MonthDayYear
Date
DOES YOUR CHILD HAVE ANY KNOWN ALLERGIES OR SENSITIVE TO:

MEDICATIONSFOODSNO ALLERGIES
If yes, please list:
Illnesses or Medical Conditions:
DOES YOUR CHILD HAVE ANY OF THE FOLLOWING CONDITIONS:

ASTHMADIABETESSEIZURESHEART PROBLEMSHEARING IMPAIRMENTVISUAL IMPAIRMENTDEVELOPMENT DELAYSPHYSICAL IMPAIRMENTBEHAVIORAL OR EMOTIONAL PROBLEMSNO KNOWN CONDITIONS
List any additional health information or special instructions you feel we need to be aware of:
List any regular medications your child takes:
Name of Child's Medical Provider:
Parent/Guardian Name
Date

MonthDayYear
Date
This form must be completed for each individual child enrolled, and must be reviewed annually by the parent/guardian, and any
Reviewed and/or update:

MonthDayYear
Date
Parent/Guardian Name

First NameLast Name
Date

MonthDayYear
Date
Parent/Guardian Name

First NameLast Name
Should be Empty:

BRIGHT MORNING STAR CHILD CARE

Child Admission Agreement

Child Health Assessment

Illnesses or Medical Conditions: