Home Childcare Application Date of Admission * MM DD YYYY Date of Discharge * MM DD YYYY Child's Name * Child 1 First Name Last Name Child's D.O.B * Child 1 MM DD YYYY Child's Name * Child 2 First Name Last Name Child's D.O.B * Child 2 MM DD YYYY Child's Name * Child 3 First Name Last Name Child's D.O.B * Child 3 MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Home Phone * (###) ### #### Email * Days of Care Needed * Hours of Care Needed * Parent Name Parent 1 First Name Last Name Cell Phone Parent 1 (###) ### #### Work Address Parent 1 Address 1 Address 2 City State/Province Zip/Postal Code Country Parent Name Parent 2 First Name Last Name Cell Phone (###) ### #### Work Address Address 1 Address 2 City State/Province Zip/Postal Code Country Legal Guardian’s Name First Name Last Name Guardian's Cell Phone (###) ### #### Guardian's Work Address Address 1 Address 2 City State/Province Zip/Postal Code Country Authorized persons who may pick up child: * 3 people max* STEPS FOR EMERGENCY MEDICAL TREATMENT In case of emergency medical treatment, the provider will administer First Aid, call 911, call the parents (or guardian), and then contact the agency. The caregiver will use the information below if parents (guardian) cannot be reached. Emergency Contact Name * First Name Last Name Phone * Emergency contact number. (###) ### #### Address * Emergency contact address. Address 1 Address 2 City State/Province Zip/Postal Code Country Relation To Child * What school does/will your child attend: * Child’s Physician * First Name Last Name Physician’s Phone * (###) ### #### Physician’s Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Previous Communicable Diseases Previous Illness or Injury Special Medical Conditions e.g. Allergies, Diabetes, Seizures, etc. Medication Administered Regularly Specify name, dosage and reason for medication. Special Diet Please comment on any other important information that is relevant for the provider to know in order to provide care for your child: * e.g. Sleep routine, development, fears etc. I authorize the administration of sunscreen, diaper cream, Vaseline and bug repellent as needed. I understand that it is my responsibility to provide the products to the provider in the original container with my child’s name on it. * Yes No I grant permission to use photographs and/or videos taken of my child(ren) during their time in care to be used in text or email communication between parent, provider and agency, for promotion of our home childcare agency (newsletters/website) and for staff/provider training. * Yes No I have read and agreed with the Parent Handbook policies and procedures. * I Agree Today's Date * MM DD YYYY Signature * Thank you!