Eaton Early Learning Center

Application
 

Date of Application: ____________________   Starting Date: ____________________
 
Child's Name (last, first, m.i.) _____________________________________________________________________


Child's Nickname (if any) __________________________ Blood Type _____


Birth date ______________________ Current Age _________Sex: Male___  Female:___


Home Address___________________________________ City____________________ State ______ Zip__________


Father/Guardian (last, first, m.i.)___________________________________________________________________


Home Address___________________________________ City____________________ State ______ Zip__________


Place of Employment _____________________________________________________________________________


Address: ______________________________________________________________________________________


Phone Numbers: Home__________________________ Work __________________________ Ext.________


                          Pager__________________________  Cell __________________________


Mother/Guardian (last, first, m.i.)__________________________________________________________________


Home Address___________________________________ City____________________ State ______ Zip__________


Place of Employment _____________________________________________________________________________


Address: ______________________________________________________________________________________


Phone Numbers: Home__________________________ Work __________________________ Ext.________


                          Pager__________________________  Cell __________________________


Parent Marital Status (   ) Married   (    ) Single    (    ) Divorced    (    ) Widowed


If divorced who has custody?________________________________________________________________________


May the non-custodial parent pick up the child? (   ) Yes   (   ) No


Please list all other siblings regardless of attendance at this facility.

First, Last ______________________________________   First, Last ______________________________________

First, Last ______________________________________   First, Last ______________________________________

The child will only be released to the parents/guardians (unless otherwise stated) designated on this application and the following persons listed below. (Please include name, address, phone and relationship)


First, Last ___________________________________________ Relationship _________________________________


Home Address___________________________________ City____________________ State ______ Zip__________


First, Last ___________________________________________ Relationship _________________________________


Home Address___________________________________ City____________________ State ______ Zip__________
 
Emergency contacts other than parents: (Please list name, home, work and cell phone numbers)


First, Last ________________________________________________________________


Home Address___________________________________ City____________________ State ______ Zip__________


Place of Employment _____________________________________________________________________________


Address________________________________________ City____________________ State ______ Zip__________


Phone Numbers: Home__________________________ Work __________________________ Ext.________


                          Pager__________________________  Cell __________________________

 
Insurance Company


Name_________________________________________________________________________


Policy Number _______________________________ Group Number ______________________

Name of Policy Holder _________________________ Relationship ________________________

Child’s Physician _____________________________________ Phone ____________________________

Address________________________________________ City____________________ State ______ Zip__________


Child’s Dentist _______________________________________ Phone ____________________________

Address________________________________________ City____________________ State ______ Zip__________

Hospital preference  __________________________________ Phone ____________________________________

Address________________________________________ City____________________ State ______ Zip__________
 

Please list any other person(s) with professional relationship to the child (i.e. counselor, therapist, doctor, etc.)

Name & Occupation _______________________________________ Phone ________________________________

Address________________________________________ City____________________ State ______ Zip__________

Name & Occupation _______________________________________ Phone ________________________________

Address________________________________________ City____________________ State ______ Zip__________