Hazardville Daycare Enrollment

							                                     Hazardville Daycare Enrollment Form
Date of Application:                                              Desired start date:

Child's Name:                                                     Child's birth date:

Parents are: Married   Living Together                            Gender:    Male
              Divorced   Other                                               Female

Child resides with:                                               School Attending:


Guardian One Name:                                                Guardian Two Name:

Relationship to child:                                            Relationship to child:

Home address:                                                     Home address:

Home phone:                                                       Home phone:

Occupation:                                                       Occupation:

Company/School:                                                   Company/School:

Work address:                                                     Work address:

Work phone:                                                       Work phone:

Hours @ work:                                                     Hours @ work:

Cell phone/pager:                                                 Cell phone/pager:

Email:                                                            Email:


Health Insurance Carrier:                                         Insurance Group #

Known Allergies:                                                  Insurance ID #

Child's Doctor:                                                   Phone:

Child's Dentist:                                                  Phone:
                                                    Emergency Contacts
Name:                                    Address:                                                Phone:




             Weekly Care Schedule                                               Transportation release
Drop off time:           Pick up time:               Hazardville Daycare Center has my permission to transport my child to
                                                     and from school. I also authorize Hazardville Daycare Center to secure
Days here:                                           medical treatment in my absence. I understand I am responsible for all
                                                     medical expenses.
         M         T   W     Th          F
                                                     Guardian Signature: