Children's Castle Childcare Inc

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Enrollment Application

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Email *

Child's Name *

First

Last

Date of Birth *

Center Interested In *

Enrollment Date *

Age *

Gender *

Class

Mother's Name *

First

Last

Mother's Address

Address Line 1

Address Line 2

City

State

Zip Code

Mother's Employer Name *

First

Last

Mother's Work Phone

Mother's CellPhone

Mother's Home Phone

Father's Name *

First

Last

Father's Address

Address Line 1

Address Line 2

City

State

Zip Code

Father's Cell Phone

Father's Employer's Name *

First

Last

Child Schedule? Home

Employer's Address

Address Line 1

Address Line 2

City

State

Zip Code

Work Phone

Home Phone

Emergency -1 Contact Name *

First

Last

E-1 Address

Address Line 1

Address Line 2

City

State

Zip Code

E-1 Work Phone

E-1 Home Phone

Emergency -2 Contact Name *

First

Last

E-2 Address

Address Line 1

Address Line 2

City

State

Zip Code

E-2 Work Phone

E-2 Home Phone

Child's Physician *

First

Last

Child's Physician Address

Address Line 1

Address Line 2

City

State

Zip Code

Child's Physician Phone

Pick up Person 1's Name *

First

Last

Pickup Person -1's Address

Address Line 1

Address Line 2

City

State

Zip Code

Pick Up Person-1's Relationship to Child

Pick Up Person-1's work Phone

Pick Up Person-1's Home Phone

Pick up Person 2's Name *

First

Last

Pickup Person -2's Address

Address Line 1

Address Line 2

City

State

Zip Code

Pick Up Person-2's Home Phone

Pick Up Person-2's Work Phone

Pick Up Person-2's Relationship to Child

Pick up Person 3's Name *

First

Last

Pickup Person -3's Address

Address Line 1

Address Line 2

City

State

Zip Code

Pick Up Person-3's work Phone

Pick Up Person-3's Home Phone

Pick Up Person-3's Relationship to Child

Pick up Person 4's Name *

First

Last

Pickup Person -4's Address

Address Line 1

Address Line 2

City

State

Zip Code

Pick Up Person-4's work Phone

Pick Up Person-4's Home Phone

Is there anyone not allowed to pick your child

Not allowed Person's Name *

First

Last

Not allowed Person's Phone

Not allowed Person's relation to child

Reason to not allow

Child's Allergies

Current Prescribed Medication

Child's Special Medical needs and Conditions

Date of Last Tetanus

Pre-School: Child Care Arrangement for Illnesses

Pre-School: Has Your Child Had The Following?

Measles (Big Red)
Measles (3 Days)
Giardia
Fifth's Disease
Hepatitis B
Chicken Pox
Whooping Cough
Other

Pre-School: Any Serious

Specify in detail if Yes

Pre-School: Any Physical Disabilities

Specify in detail if Yes

Any Medication To Be Given Regularly

Child's Food Allergies

Child's Insect Allergies

Child's Medication Allergies

Child's Other Allergies

Can the Child Reliably Indicate Bathroom Wishes?

Does the child have frequent toilet accidents?

How Does Your Child Reach to Them?

What Time Does Your Child Awaken From Bed?

What Is Your Child's Mood On Awakening?

What Is Your Child's Nap Schedule?

Will Your Child Adjust Easily To Child Care?

How Does Your Child Show His/Her Feelings?

What Makes Your Child Angry or Upset?

By Nature, Is Your Child

Friendly
Shy
Withdrawn
Aggressive

Is your child frightened by any of the following?

Animals
Dark
Stories
Loud Noise

I have read and accept the statement to the right

Yes

I certify that the facts contained in this application are true and complete to the best of my knowledge

Quick Links

Parent Expertise
Contact
Enrollment Application

Contact Us

301 Yaupon Drive, Jacksonville, NC28546
childrenscastlechildcareinc@gmail.com
+1 910-346-8555

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