DALLAS HIGH SCHOOL

Dallas, Pennsylvania

CHILD CARE AND DEVELOPMENT

ENROLLMENT FORM

Child’s Full Name                                                                                                         

Child’s Birth Date                                             Sex                              

Name by which child should be called:                                                                           

Father’s Full Name                                                        Occupation                                          

Mother’s Full Name                                                      Occupation                                 

Child’s Full Address                                                                                                                 

Phone Number                                     

Other children in family (Please list by name, age, and sex)

Any toilet training problems at present:

Health history: Please indicate immunizations the child has had.  Describe and physical or medical concerns of which we should be advised.

Any allergies at present:                                                                                             

Who will bring the child:                                                                                             

Who will pick up the child:                                                                                          

In case of emergency, contact:                                                                                    

Phone                                      

Please note any serious illness in the family, absence of parents, divorce, etc., which may affect the child’s behavior, or any problems of which you feel we should be advised, such as shyness, speech problems, temper tantrums, etc.