Child's Name_________________________________________________________________

Birthday _______________________________________________________________________

What name does the child like to be called?____________________________________

Mother’s Name __________________________________________________________________

Full Addres_____________________________________________________________

Home Phone _______________________________________________________________

Cell Phone/Beeper_______________________________________________________________

Place of Employment______________________________________________________

Work Phone ___________________________ Regular Working Hours___________________

Father’s Name______________________________________________________________

Full Address______________________________________________________________

Home Phone_____________________________________________________________

Place of Employment _____________________________________________________

Work Phone____________________________ Regular Working Hours___________________

Is the child living with ____________mother?__________father?__________both parents?

                         ____________others?

Who has legal custody of the child?__________________________________________________________



Other Children in the Family:	

Name                          Birthday                           School Attending

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Emergency Information:

Identify the adult(s) who is/are authorized to act for you in the event of an emergency:


Name________________________________________________________________________

Full Address_____________________________________________________________

Where Employed ______________________________Work Phone_______________________

Address_____________________________________ Work Hours______________________

Name________________________________________________________________________

Full Address _________________________________________________________________

Where Employed __________________________ Work Phone_____________________________

Address__________________________________________________________

Work Hours_______________________________________________

Physician’s Name_______________________________________________________________

Full Address________________________________________________________________

Office Phone________________________ Home Phone_______________________________

Transportation Plan: To insure the safety of your child, please list other adults to whom your child may be released 
or who are authorized to provide transportation for your child.



Name                   Phone                     Relationship to the Child

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

The information stated above is current and adequate.  I understand that it is my responsibility to notify 
the day care of any changes.

______________________________________________________________Parent/GuardianSignature

______________________________________________________________Parent Guardian/Signature

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For Scarboro Day Care Use Only:

Date Application Received:_________________________		

Date Child Enrolled:_______________________________

Date Child Withdrawn:______________________________

Reason for Withdrawal:_____________________________