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Home
About
Overview
Location
Philosophy
Special Programs
Tuition & Fees
Info
News
Docs & Resources
Contact
Epiphany
Early Childhood Center
Epiphany Church
Application
Epiphany Early Childhood Center Childcare Application
Please complete and submit
Name of Child
*
First Name
Last Name
Nickname
Date of Birth
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Father/Guardian's Name
*
First Name
Last Name
Father/Guardian's Phone
*
(###)
###
####
Father/Guardian's Alternate Phone
(###)
###
####
Father/Guardian's Email
*
Father/Guardian's Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Father/Guardian's Place of Employment
Mother/Guardian's Name
*
First Name
Last Name
Mother/Guardian's Phone
*
(###)
###
####
Mother/Guardian's Alternate Phone
(###)
###
####
Mother/Guardian's Email
Mother/Guardian's Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Mother/Guardian's Place of Employment
Child's Insurance Carrier
*
Insurance Policy Number
*
Does your child have any known allergies?
*
Yes
No
If yes, please explain:
Does your child have any chronic illnesses/conditions?
*
Yes
No
If yes, please explain:
Please give any information concerning your child which will be helpful in his/her experience in group setting (such as play, eating and sleeping habits, special fears, special likes or dislikes).
Name of Child's Doctor
*
First Name
Last Name
Doctor's Phone
*
(###)
###
####
Doctor's Address
*
Hospital Preference
*
Hospital Phone
*
(###)
###
####
Emergency Contact 1
*
First Name
Last Name
Relationship to Child
*
Emergency Contact 1 Phone
*
(###)
###
####
Emergency Contact 1 Alternate Phone
(###)
###
####
Emergency Contact 2
First Name
Last Name
Relationship to Child
Emergency Contact 2 Phone
(###)
###
####
Emergency Contact 2 Alternate Phone
(###)
###
####
If you cannot call for your child, please give the names of persons to whom the child can be released:
*
By checking this box, I 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.
*
I agree
Date
*
MM
DD
YYYY
By checking this box, I understand that the operator agrees 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 understand that the operator will not administer any drug or medication without specific instructions from the physician or the child's parent, guardian, or full-time custodian. I understand that provisions will be made for adequate and appropriate rest and outdoor play.
*
I undersand
Date
*
MM
DD
YYYY
Thank you!
