Child(ren)'s Name:

Child(ren)'s Date of Birth:

Child(ren)'s Ages:

Mother's Name:

Mother Social Sec #:

Father's Name:

Father Social Sec #:
(SS#'s are for record purposes ONLY and will not be used for any other reason, HOWEVER - they MUST be provided.)

Home Phone Number:

Home Address:
Mother's Employer:

Phone:

Father's Employer:

Phone:

Authorized Caretakers approved to pick up your child:

Name: Phone:

Name: Phone:

Name: Phone:

Name: Phone:

Name: Phone:

Name: Phone:

If your child is in need of emergency care and parent can not be reached, who should I contact?
Name: Phone: Relationship:

Name: Phone: Relationship:

Pediatrician's Name: Phone Number:

Please list Hospital Preference AND any medical information pertinent (ex: allergies, activity restrictions, etc.) to the care of your child:

Design your own schedule: (5 hour minimum.)
Scheduled Days:

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Scheduled Hours:
Estimated Arrival Time:

Estimated Departure:
Projected Weekly Tuition: $(Paid 1st day of schedule for new week)
Please read the following statements and sign and date below:

• In case of emergency, I authorize Chris Reid to obtain medical care for my child.
• I have read the policies sheet and will comply with the policies of Chris Reid and/or HandPrints Home Childcare Center.

Date:

• Parent's can sign this form when they come to visit the childcare.