EmailMe Form - VDOT Child Care Application for Enrollment

Student Information

Date of Birth

Sex

Name

First Middle Last

Nickname

Child's Physical Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Primary Hours of Care

Days of the Week in Care

Family Information

Child Lives With

mother, father, etc.

Mother's Name

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone

### - ### - ####

Employer

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone

### - ### - ####

Father's Name

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone

### - ### - ####

Employer

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone

### - ### - ####

Custody

Mother

Father

Both

Other

Medical Information

I hereby grant permission for the staff of this facility to contact the following medical personnel to obtain emergency medical care if warranted.

Doctor

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone

### - ### - ####

Doctor

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone

### - ### - ####

Dentist

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone

### - ### - ####

Hospital Preference

Please list allergies, special medical or dietary needs, or other areas of concern

Emergency Care Plan instructions (if applicable)

Emergency Contacts

Child will be released only to the custodial parent or legal guardian and the persons listed below. The following people will also be contacted and are authorized to remove the child from the facility in case of illness, accident or emergency, if for some reason, the custodial parent or legal guardian cannot be reached

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Work Phone

### - ### - ####

Home/Cell Phone

### - ### - ####

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Work Phone

### - ### - ####

Home/Cell Phone

### - ### - ####

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Work Phone

### - ### - ####

Home/Cell Phone

### - ### - ####

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