Epiphany Early Childhood Center Childcare Application

 

Please complete and submit

Name of Child *
Name of Child
Address *
Address
Father/Guardian's Name *
Father/Guardian's Name
Father/Guardian's Phone *
Father/Guardian's Phone
Father/Guardian's Alternate Phone
Father/Guardian's Alternate Phone
Father/Guardian's Address *
Father/Guardian's Address
Mother/Guardian's Name *
Mother/Guardian's Name
Mother/Guardian's Phone *
Mother/Guardian's Phone
Mother/Guardian's Alternate Phone
Mother/Guardian's Alternate Phone
Mother/Guardian's Address *
Mother/Guardian's Address
Name of Child's Doctor *
Name of Child's Doctor
Doctor's Phone *
Doctor's Phone
Hospital Phone *
Hospital Phone
Emergency Contact 1 *
Emergency Contact 1
Emergency Contact 1 Phone *
Emergency Contact 1 Phone
Emergency Contact 1 Alternate Phone
Emergency Contact 1 Alternate Phone
Emergency Contact 2
Emergency Contact 2
Emergency Contact 2 Phone
Emergency Contact 2 Phone
Emergency Contact 2 Alternate Phone
Emergency Contact 2 Alternate Phone
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. *
Date *
Date
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. *
Date *
Date