BRIGHT MORNING STAR CHILD CARE APPLICATION FORM

Child Admission Agreement
Name of Child

First NameMiddle NameLast Name
Nickname
Child's Birthdate

MonthDayYear
Date
Child's Sex
Child's Sex
Date of Enrollment (For management to enter, unless start date is known.)

MonthDayYear
Date
(For administrative use.)
Home Street Address
City
State
Zip
Home Phone #
Parent's/Guardian's Name #1
Parent's/Guardian's Cell Number #1

Area CodePhone Number
Parent's/Guardian's Work Number #1

Area CodePhone Number
Parent's/Guardian's Work Phone #1
Parent's/Guardian's Email #1
example@example.com
Parent's/Guardian's Name #2
Parent's/Guardian's Cell Number #2

Area CodePhone Number
Parent's/Guardian's Work Phone #2

Area CodePhone Number
Parent's/Guardian's Work Phone #2
example@example.com
Parent's/Guardian's Work Phone #
Parent's/Guardian's Email #2
example@example.com
EMERGENCY CONTACTS AND PERSONS AUTHORIZED TO PICK UP CHILD (other than parents) Unless there is a court order prohibiting it, parents whose names are not listed can pick up their children.
Name of Emergency Contact #1

First NameLast Name
Relationship to Child of Emergency Contact #1
Address of Emergency Contact #1
Phone Number of Emergency Contact #1

Area CodePhone Number
Name of Emergency Contact #2

First NameLast Name
Relationship to Child of Emergency Contact #2
Address of Emergency Contact #2
Phone Number of Emergency Contact #2

Area CodePhone Number
Name of an Out-Of-Area Contact (if applicable)
Relationship to Child of Out-Of-Area Contact
Address of Out-Of-Area Contact
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 treatment and transportation for my child.
Phone Number of Out-Of-Area Contact

Area CodePhone Number
Name of Parent/Guardian
Signature
Date

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

Other
Name of Parent/Guardian
Signature
Date

MonthDayYear
Date
The parent/guardian must review this form annually and note any changes.

(Leave these dates and signatures blank if this is a new application.)
Date of 1st Annual Renewal (skip if new application)

MonthDayYear
Date
Name

First NameLast Name
Parent Signature After 1st Annual Renewal (skip if new application)
Date of 2nd Annual Renewal (skip if new application)

MonthDayYear
Date
Name

First NameLast Name
Parent Signature After 2nd Annual Renewal (skip if new application)
Date of 3rd Annual Renewal (skip if new application)

MonthDayYear
Date
Parent Signature After 3rd Annual Renewal (skip if new application)
Child Health Assessment
Name of Child
Birth Date

MonthDayYear
Date
DOES YOUR CHILD HAVE ANY KNOWN ALLERGIES OR SENSITIVITIES TO:
MEDICATIONS
If yes, please list:
FOODS
If yes, please list:
OTHER
If yes, please list:
Are any listed allergies life-threatening?
If yes, please indicate which one and provide important details.
CHECK ALL THAT APPLY TO YOUR CHILD'S MEDICAL CONDITION:
List any other applicable illnesses or medical conditions not listed above:
Explain any additional health information or special instructions you feel we need to be aware of:
List any regular medications your child takes OR mark as N/A:
Name of Child's Medical Provider:
Parent/Guardian Name
Signature
Date

MonthDayYear
Date
This form must be completed for each individual child enrolled, and the parent/guardian must review it annually and note any changes. (Leave these dates and signatures blank if this is a new application.)
Date of 1st Annual Renewal (skip if new application)

MonthDayYear
Date
Parent/Guardian Name

First NameLast Name
Parent Signature After 1st Annual Renewal (skip if new application)
Date of 2nd Annual Renewal (skip if new application)

MonthDayYear
Date
Parent/Guardian Name

First NameLast Name
Parent Signature After 2nd Annual Renewal (skip if new application)
Date of 3rd Annual Renewal (skip if new application)

MonthDayYear
Date
Parent Signature After 3rd Annual Renewal (skip if new application)
Family Needs Assessment
This section will help us match your child to the best spot at one of our locations.

While we specialize in working with parents' schedules, we cannot accommodate everybody. Decisions are made on a case-by-case basis, according to current openings and schedules of other enrollees. We are NOT a 24-hour facility.

If we don't have a current opening that meets your needs, we may give you the option of being added to a waiting list.
Name of Child

First NameLast Name
Age of Child
Name of Child's School
ARE YOU ALSO APPLYING TO ENROLL OR HAVE ALREADY ENROLLED ANY OF THEIR SIBLINGS? PLEASE LIST:
Name of 1st Sibling Already Enrolled or to be Enrolled:

First NameLast Name
Age of 1st Sibling:
Name of School 1st Sibling Attends:
Name of 2nd Sibling Already Enrolled or to be Enrolled:

First NameLast Name
Age of 2nd Sibling:
Name of school 2nd Sibling Attends:
Name of 3rd Sibling Already Enrolled or to be Enrolled:

First NameLast Name
Age of 3rd Sibling:
Name of school 3rd Sibling Attends:
Name of 4th Sibling Already Enrolled or to be Enrolled:

First NameLast Name
Age of 4th Sibling:
Name of school 4th Sibling Attends:
SCHEDULE NEEDS
How often do you need childcare?

Other
Which days of the week? (You can choose more than one.)
If your schedule rotates, list the days you rotate through:
How many hours per day do you typically need?
What time of day do you typically need childcare? (Can choose more than one.)

Other
Is there any further information you would like us to know about your schedule?
For which activities do you typically need childcare? (Can choose more than one.)

Other
SPECIAL CARE NEEDS
Which best describes this child's diapering/potty needs?

Other
Mark any special needs. (We will reference the above application for the details.)
Do you have any transportation needs?
Should be Empty:

Child Admission Agreement

Child Health Assessment

Family Needs Assessment