Your Child's Information

Intended Start Date:

Child's First Name*:

Middle Name(s)*:

Last Name*:

Preferred Name
to be called*:

Child's Primary Address*:

Date of Birth*:

Gender*:

Male Female Other

Primary Language Spoken At Home*:

Home Phone*:

Last 4 of SSN*:

Family Member Name*:

Relationship to Child:

+ Add a Family Member

Allergies

Allergy

Reaction

Severity

+ Add an Allergy

Child's Primary Doctor

Doctor's Name*:

Clinic's Name*:

Clinic's Address*:

Clinic's Phone Number*:

Preferred Hospital
(if possible):

Insurance Provider*:

Insurance Policy Number*:

Child's Primary Dentist

N/A:

Dentist's Name:

Clinic's Name:

Clinic's Address:

Clinic's Phone Number:

Insurance Provider:

Insurance Policy Number:

Health History

Is Your Child
Fully Immunized:

Ear Infections:

Nose Bleeds:

Diabetes:

Heart Disease
/Defects:

Convulsions
/Seizures:

Asthma:

Please upload any Health Care Plans / Health Appraisals / Immunization Records here:

Only pdf, doc and docx file formats are allowed.

Operation/Serious Injuries

Date

Description

+ Add an Operation/Serious Injury

Current Medications

Name of Medication

Dose

Frequency

+ Add a Current Medication

Please List Any Existing Medical Conditions,Medication And/Or Special Attention to Your Child May Require (Not Mentioned Above)

Photo Permission

I authorize the use of my child’s photograph in any school publication including but not limited to the school's
brochure, newsletters and websites

Additional Comments/Information

Is there any additional information that our teachers and staff need to know about this child?

Save and Continue

Parent / Guardian Information

Prefix:

Name*:

Address*:

Call This Parent:

Home Phone*:

Mobile Phone*:

Email Address*:

Relationship to Child*:

Employer's Name*:

Work Address*:

Work Phone*:

Driver's License No.*:

State*:

Special instructions for reaching this adult:

Save and Continue Back

Emergency Contacts - Please list 2 that are NOT Parents

No Emergency Contacts Available Other Than Parents:

Full Name*:

Relationship to Child*:

Address*:

Primary Phone Number*:

Alternative Phone Number:

Full Name*:

Relationship to Child*:

Address*:

Primary Phone Number*:

Alternative Phone Number:

Child Pickup Authorization

Authorized Person's Name*:

Relationship to Child:

NOT Authorized For Pickup

NOT Authorized For Pickup:

Upload Court Documentation (if applicable):

Only pdf, doc and docx file formats are allowed.

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Congratulations!

Your Information Has Been Received

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Please enter an email address that you can open on your phone.

	OUR LOCATION
	Little Steps Childcare 1001 Anywhere Ln. Happytown, CO 80222
	303.555.1212
	CENTER HOURS
	7:00 am to 5:30 pm

Your Child's Information

Allergies

Child's Primary Doctor

Child's Primary Dentist

Health History

Operation/Serious Injuries

Current Medications

Physical Limitations

Dietary Limitation

Are there any activities you would prefer your child NOT to participate in?

Photo Permission

Additional Comments/Information

Parent / Guardian Information

Emergency Contacts - Please list 2 that are NOT Parents

Child Pickup Authorization

NOT Authorized For Pickup

Congratulations!

Your Information Has Been Received

OUR LOCATION

CENTER HOURS