Enrollment Application

Information About your Child
Does your child have any known allergies?*
- Yes
- No
Allergies
Does your child have any known medical conditions?*
- Yes
- No
Your Child's Medical Conditions
Please list any allergies and explain any medical conditions
Is you child covered by medical insurance?*
- Yes
- No
Insurance Carrier*
Policy Number*
Additional Information
Please give any information concerning your child which will be helpful in his or her experience in group settings; such as playing, eating and sleeping habits, special fears, special likes or dislikes, etc...

Medical Information
Name of child’s doctor*
Doctor's Phone Number
Doctor's Address
Street Address City ZIP / Postal Code
Name of child’s dentist
Dentist's Address
Street Address City ZIP / Postal Code
Hospital Preference*
- Chapel Hill Urgent Care
- UNC Health Care
- Durham Regional

Contact Information
Primary Emergency Contact*
- Father (Guardian 1)
- Mother (Guardian 2)
Alternate Emergency Contacts*
First Name Last Name Relationship Cell Phone Office Phone

Please list persons to be contacted if both father and mother (or guardian) can not be contacted.
Child Release Contacts
First Name Last Name Relationship

Please list the names of persons to whom the child can be released.

Authorization
Parent Authorization
I as the parent or guardian agree that the operator may authorize the physician of his/her choice to provide emergency care in the event that neither I nor the family physician can be contacted immediately.
Signature*
Center Authorization
I, as the operator, do agree to provide transportation to an appropriate medical resource in the event of emergency. In an emergency situation, other children in the facility will be supervised by a responsible adult. I will not administer any drug or any medication without specific instructions from the physician or the child’s parent, guardian, or full-time custodian. Provisions will be made for adequate and appropriate rest and outdoor play.

Signature*

General Information

First Name	Last Name	Relationship	Cell Phone	Office Phone

First Name	Last Name	Relationship