Child Enrollment Form

Child & Program Information

Enter the child’s details exactly as requested on DCY 01234 (Rev 8/2025).

Day Care Name

Child’s Name *

Date of Birth *

First Day at Program/Home *

Home Address *

City *

State *

ZIP Code *

Home Telephone Number

Parent / Guardian #1 Information

Primary parent or guardian contact details.

Parent / Guardian Name #1 *

Relationship to Child *

Home Address

Same as child's

City

State

ZIP

Home Telephone Number

Email Address (if applicable)

Cell Phone (if applicable)

Parent’s Work/School Name

Parent’s Work/School Telephone Number

Parent’s Work/School Address

City

May this name be released if another parent/guardian requests contact information? *

Yes No

If “Yes”, what information should be included on the list?

Work # Cell # Home # Email

Where can you be reached while your child is in the program/home?

Parent / Guardian #2 Information

Secondary parent or guardian details (if applicable).

Parent / Guardian Name #2

Relationship to Child

Home Address

Same as child's

City

State

ZIP

Home Telephone Number

Email Address (if applicable)

Cell Phone (if applicable)

Parent’s Work/School Name

Parent’s Work/School Telephone Number

Parent’s Work/School Address

City

May this name be released if another parent/guardian requests contact information?

Yes No

If “Yes”, what information should be included on the list?

Work # Cell # Home # Email

Where can you be reached while your child is in the program/home?

Emergency Contacts

Parents or guardians cannot be listed as emergency contacts. Please list at least one person who can be contacted in an emergency or illness if you cannot be reached. At least one must be 18+ and able to take responsibility for the child.

Emergency Contact 1

Name *

Emergency Contact 1 - Street Address *

City

State

Telephone Number *

Relationship to Child *

Other numbers where this contact can be reached (if applicable)

Emergency Contact 2

Name

Emergency Contact 2 - Street Address

City

State

Telephone Number

Relationship to Child

Other numbers where this contact can be reached (if applicable)

Health & Medical Information

Complete this section accurately. If your child requires special medical care or medication, additional DCY forms may be required.

Physician or Clinic / Hospital Information

Name of Physician or Clinic/Hospital *

Preferred Hospital *

Street Address

City

State

Telephone Number *

Allergies, Special Health or Medical Conditions, and Medical Foods

Does your child have any food, medication, or environmental allergies? *

No Food Medication Environmental

Please list and explain:

Does your child’s allergy/allergies require staff to monitor or administer medication? *

No Yes — requires DCY 01236 Child Medical/Physical Care Plan

Special Health or Medical Conditions

Does your child have a developmental delay or special health condition?

No Yes — please explain below

Explanation (if applicable)

Does this condition require staff to perform care or administer medication?

No Yes — requires DCY 01236 form

Medication / Medical Food

Is your child currently using any medication or medical food?

No Yes — please explain below

If Yes, please explain

Does this medication/food need to be administered at the program/home?

No Yes — requires DCY 01217 & DCY 01236 forms

Dietary Restrictions

Does this dietary restriction eliminate all fluid milk or entire food group?

No Yes (requires healthcare provider documentation) N/A — program does not provide meals/snacks

If Yes, please explain

Does this restriction eliminate all types of milk or an entire food group?

No Yes — written instructions from healthcare provider required N/A — program does not provide meals/snacks

Additional Child Information

Provide details that would be helpful for staff to know.

List any history of hospitalization, outpatient surgery, or previous health concerns

Fears or preferred comfort methods

Eating or sleeping habits

Special routines or behavioral needs

Persons Authorized to Pick Up Child (in addition to parents/guardians)

List at least one person authorized to pick up your child other than parents/guardians.

Name *

Phone *

Relationship *

Diapering & Emergency Transportation Authorization

Diapering Statement

Is your child toilet trained? *

Yes (Skip to Emergency Authorization) No (Complete below)

The program checks diapers every ___ hours

Please indicate preference

I agree with the program’s schedule I do not agree, please check my child’s diaper every ___ hours

Emergency Transportation Authorization

Give Permission to Transport — or — Do Not Give Permission (choose one)

Program or Home Name

Choose One:

I GIVE permission for the program/home to secure emergency transportation for my child in case of illness or injury requiring treatment. I DO NOT give permission for emergency transportation. I wish for the following action to be taken:

If you selected "No", describe alternate action:

Parent's Signature *

Date *

Policy Acknowledgment & Signatures

I have reviewed and received a copy of the program’s policies and procedures handbook. (check one) *

Yes No

Parent/Guardian Signature(s) *

Date *

Administrator/Designee Signature

Date