Enrollment Application

(*) required field

Child's Name*	Gender*	Date of Birth*
Child's Address *	Phone*
City/State*	ZIP*

How did you first hear about us? Other

Admission status desired Full-time Part-time (equivalent to twelve full-days or twenty half-days per mo.)

Date of application Date of admission desired

Family Information

Father's Name Work Hours

Home Address Home Phone

Employer Work Phone

Work Address ZIP

Email Contact

Mother's Name Work Hours

Home Address Home Phone

Employer Work Phone

Work Address ZIP

Email Contact

Other people in the primary residence:

Name Age Gender

General Information

Describe previous daycare experience:

Information helpful for us to know about your child:

Would you like to be contacted by someone from Temple Baptist Church?
Yes No

Health Information

Please check the common childhood diseases that your child has had:
chicken pox german measles mumps measles

List any known allergies or other physical problems:

If your child is regularly on medication, please explain:

Emergency Information

If neither mother or father can be reached, who may we contact?

Name		Phone
Address		Relationship
Child's Doctor		Phone
Child's Dentist		Phone
Health Insurance		Group #

People who are authorized to take my child from Sonbeam:
Name Phone Relationship

Name Phone Relationship

Emergency Authorization

In the case of an emergency, the employees of Sonbeam Daycare Center have my permission to take my child by ambulance to medical care at my expense

I agree signature of parent or guardian Date

Condition of enrollment

I understand that reasonable effort will be made to accomodate my child in the existing program at Sonbeam. I also understand that it is necessary for any child enrolled to be able to meet the minimum behavior standard of being able to obey the rules of the daycare so that he/she can be kept safe and other children or staff members are not at risk of safety by their actions. I agree to these conditions.
I agree signature of parent or guardian Date