COMMUNITY CHILDCARE FOOD SUPPLEMENT, INC.

ENROLLMENT FORM APPLICATION

_________________
Day Care #: ______________ Mother’s #:______________
CHILD(REN)’S INFORMATION:
Child’s Name (1) ___________________________________ Date of Birth ______ / ______ / ______
AGE_________
Mo Day Yr
Child’s Name (2) ___________________________________ Date of Birth ______ / ______ / ______
AGE_________
HOME ADDRESS: _________________________________ Home Phone # ____________________
__________________________________________________ Cell Phone # _____________________
SCHOOL INFORMATION FOR MORNING OR AFTER SCHOOL CARE CHILDREN ONLY
NAME OF SCHOOL (1) _________________________________ Grade (1) _____ Open ___:____ Close
___:____
NAME OF SCHOOL (2) _________________________________ Grade (2) _____ Open ___:____ Close
___:____
PARENTS YOU SHOULD KNOW YOUR CHILD’S MEAL TIMES IN THE DAY CARE
My child(ren) participate(s) in the following MEALS AT THIS DAY CARE:
TIME: [ ] Breakfast ___:____ [ ] AM Snack ___:____ [ ] Lunch ___:____ [ ] PM Snack ___:____
[ ] Supper___:____You Must Sign Your Child In/Out if He/She eats Supper at or after 5:00pm.

I bring my child to the day care at _____:______ and I pick my child up at _____:______

PARENTAL INFORMATION:
Mother’s Name _______________________________________ Work Hours ______:________ to
______:_______
Work Name and Address _______________________________ Work Phone _____________________________
____________________________________________________ Home Phone ____________________________
Father’s Name _______________________________________ Work Hours ______:________ to
______:______
Work Name and Address _______________________________ Work Phone _____________________________
____________________________________________________ Home Phone
_____________________________

Special Needs of Child [ ] NO or [ ] YES (If yes, please attach Dr. Statement)
Medical Information (allergy, sickness, etc.) [ ] NO or [ ] YES Explain_____________________________________
In case of injury or accident Physician’s Name/ Physician’s Phone/ Hospital of
Choice________________________________________________
Parent’s Signature:__________________________ I hereby give permission to treat my child(ren) in case of medical
emergency.
Date________________________

NAMES OF TWO OTHER PERSONS THAT CAN BE CONTACTED IN CASE OF EMERGENCY

Name ______________________________________ Name ______________________________________
Address _____________________________________ Address _____________________________________
Phone _____________________________________ Phone _____________________________________

Child (1) is: A. [ ] Related to Provider [ ] Paying for Care

B. [ ] Related to Provider [ ] Not Paying for Care

PLEASE ADD THIS NAME TO YOUR ENROLLMENT ROSTER

 COMMUNITY CHILDCARE FOOD SUPPLEMENT, INC. ENROLLMENT FORM APPLICATION
C. [ ] Not Related to Provider [ ] Paying for Care
D. [ ] Not Related to Provider [ ] Not Paying for Care
I agree that the information is correct and that a new form will be completed if I change my address or telephone
number or any other pertinent information listed above.

Parent’s Signature: ___________________________ Date

NOTE: Provider Must Review This Enrollment Form and Verify that all Information Is Complete before Submitting to Office.

Internal Use Only: VERIFIED_________________________________________ DATE_____________

PLEASE ADD THIS NAME TO YOUR ENROLLMENT ROSTER