Our Future Early Leaning

Center
Enrollment Information
2019-2020
 ITEMS NEEDED TO ENROLL
GUARDIANS CURRENT VALID PHOTO
ID
CHILD’S STATE ISSUED BIRTH
CERTIFICATE
CURRENT PROOF OF PHYSICAL EXAM
OR WELL CHILD
CURRENT EYE EXAM

CURRENT DENTAL EXAM

DOCUMENTATION OF ANY SPECIAL

NEEDS IF NEEDED
COMPLETED AND SIGNED
APPLICATION
APPLICATIONS FEE PAID IN FULL

GURADIANS PROOF OF INCOME

*current means within the last six months prior to date of application
Our Future Early Learning Center
111-222-3333

Application Form
2019-2020 school year

ENTERANCE DATE: _______________________________

Child’s name: ______________________________________________
Age: ______ Date of Birth: __________________ Sex: _____ Race: ________
Home Address (street) ______________________________________________
City ___________________________ state ___________ zip _______________
Home phone: _________________________
Alternant phone number: ____________________________________
Father’s name ________________________________________________
Mother’s name _________________________________________________
Father’s address (if different form child)
______________________________________________________________________________
______________________________________________________________________________
Father’s place of Employment: ________________________________________________
Mother’s address (if different from child)
______________________________________________________________________________
______________________________________________________________________________
Mother’s place of Employment: _________________________________________________

Child’s living arrangements: check one ()Both parents () mother () Father () other
Child’s legal guardian(s): check one () Both Parents ()mother () father () other
The child may be released to the person(s) signing this agreement or to the following:
Name Relationship to child Contact information

Persons to contact in the case of emergency when parent or guardians cannot be reached:
Name: _____________________________________ Phone: __________________________
Name: _____________________________________ Phone: __________________________
Name: _____________________________________ Phone: __________________________

 Days My child will attend circle all that apply:

Monday Tuesday Wednesday Thursday Friday

 Times my child will attend circle all that apply:

AM only PM only ALL day
 MEDICAL INFORMATION
Child’s Doctor or Clinic: _________________________________________________
Doctor/Clinic phone Number: ____________________________________________
Child has following special needs:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
The following special accommodations may be required to most effectively meet my child’s
needs while at the center:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
My child is currently on medications prescribed for long-term continuous use and/or has the
following pre-existing illness, allergies, or health concerns:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

I, _____________________________, give permission for _____________________ Earlyt

learning Center to contact my child’s doctor to obtain any prevalent necessary information about
my child’s conditions list above as they need to better serve my child while at the center.

____________________________________________
Signature Date
EMERGENCY MEDICAL AUTHORIZATION

Should (child’s name) __________________________________ Date of Birth ______________

suffer an injury or illness while in the care of (facility name) ____________________________
and the facility is unable to contact me (us) immediately, it shall be authorized to secure such
medical attention and care for the child as may be necessary. I (we) shall assume responsibility
for payment of services.

Parent or Guardian: _________________________________________________________

Print Signature
Date: ________________________________

Facility Administration/ person-in-charge: ___________________________________________

Print Signature
Date: ______________________________