Enrollment Application and Admission Record

Version 2026.1 · Effective August 23, 2026

Enrollment and child information

Date of enrollment: ____________________
Child’s full name: ______________________________________________
Preferred name: _________________________________________________
Date of birth: ____________________
Social Security number: _________________________________________
Home address: __________________________________________________
Phone number: _________________________________________________

Parent or guardian information

Parent or guardian 1

Name: __________________________________________________________
Social Security number: _________________________________________
Contact phone number(s): ________________________________________
Address, if different from child: _________________________________
Employer name: _________________________________________________
Employer address: ______________________________________________
Employer phone number: __________________________________________
Email address: __________________________________________________

Parent or guardian 2

Name: __________________________________________________________
Social Security number: _________________________________________
Contact phone number(s): ________________________________________
Address, if different from child: _________________________________
Employer name: _________________________________________________
Employer address: ______________________________________________
Employer phone number: __________________________________________
Email address: __________________________________________________

Emergency and medical information

Emergency contact name: _________________________________________
Emergency contact address: ______________________________________
Emergency contact phone: ________________________________________
Child’s doctor, address, and phone: _______________________________
Child’s dentist, address, and phone: ______________________________
Hospital of choice: ______________________________________________
Hospital of choice address: ______________________________________
Hospital of choice phone: ________________________________________
Insurance information: __________________________________________

What illnesses has your child had in the past month? ______________

________________________________________________________________

What treatment was given? ________________________________________

________________________________________________________________

When was the last prescription medicine given to this child? _______
Has your child had any illness in the past 24 hours? _______________
If so, describe the illness and treatment: _________________________

________________________________________________________________

Family and home information

Other children in the family and their relationship to the child:

________________________________________________________________

Other adults in the family and their relationship to the child:

________________________________________________________________

Child’s normal schedule

What does the child usually eat for breakfast? ____________________
What time does the child usually eat breakfast? ____________________
What time does the child usually take an AM nap? __________________
What time does the child usually wake from an AM nap? _____________
What time does the child usually eat lunch? ________________________
What time does the child usually take a PM nap? ____________________
What time does the child usually wake from a PM nap? ______________

Information about the child

Please provide information that will be helpful to the childcare provider.

Play habits: ____________________________________________________

________________________________________________________________

Eating behavior: _________________________________________________

________________________________________________________________

Sleeping pattern: ________________________________________________

________________________________________________________________

Fears: __________________________________________________________

________________________________________________________________

Likes and dislikes: ______________________________________________

________________________________________________________________

Other: __________________________________________________________

________________________________________________________________

The child’s temperament is usually: ______________________________

________________________________________________________________

Does the child have a comfort item for resting? ☐ No ☐ Yes
If yes, what is it? ______________________________________________
Routine for putting the child to sleep: ____________________________

________________________________________________________________

Does the child sleep on their side? ☐ No ☐ Yes

Is your child toilet trained? ☐ No ☐ Yes
If not, are they trying to use the toilet? ☐ No ☐ Yes
What words does the child use for the bathroom? ____________________
Does your child have any special needs or behaviors the provider

should be aware of? ______________________________________________

________________________________________________________________

Childcare information

Do you have a back-up provider? ☐ No ☐ Yes
If yes, name, address, and phone number: ___________________________

________________________________________________________________

Previous childcare experience, including dates: ____________________

________________________________________________________________

Are there any holidays you do not want to participate in? __________
Are there any foods you do not want your child to eat? ______________
Any other information about your family or child: _________________

________________________________________________________________

Requested schedule

Requested start date: ____________________
Requested days: ☐ Monday ☐ Tuesday ☐ Wednesday ☐ Thursday
Requested arrival time: __________ Requested pickup time: __________
Requested schedule or notes: ______________________________________

Enrollment is subject to availability, completed records, licensing requirements, and the signed contract.

Permission for activities

I/We give Teida’s Tots permission to take my/our child, ____________________, off the premises and on excursions during regular childcare hours. I/We understand that I/we will be notified of trips beforehand, that trips will be supervised, and that precautions will be taken for the safety and well-being of the children.

Please initial any activity below that your child does not have permission to participate in:

Ride in provider’s car (children will use proper car seats): _________
Go for walks: ___________________________________________________
Ride a bike: ____________________________________________________
Play in water: __________________________________________________
Go to a park: ___________________________________________________
Ride in wagon or stroller: ________________________________________
Go on field trips: ________________________________________________
Visit neighbors: _________________________________________________
View television or other media: __________________________________
Other: __________________________________________________________

Are there any other activities in which your child should not participate?

__________________________________________________________________

Photo permission

I/We give Teida’s Tots permission to use our child’s photograph in website, flyer, brochure, or other daycare-related publications. I/We understand that our child’s first or last name will not be used in such publications.

Child’s name: ___________________________________________________
Parent or guardian initials: ______________________________________

Child release information

No child may be released from the provider’s home to anyone other than a parent or person designated in writing by a parent. Authorized pickup persons, including parents, must present photo identification until easily recognized by the provider.

The following persons have permission to pick up my child:

Authorized pickup 1

Name: __________________________________________________________
Phone: __________________________________________________________
Relationship to child: ___________________________________________

Authorized pickup 2

Name: __________________________________________________________
Phone: __________________________________________________________
Relationship to child: ___________________________________________

Authorized pickup 3

Name: __________________________________________________________
Phone: __________________________________________________________
Relationship to child: ___________________________________________

Authorized pickup 4

Name: __________________________________________________________
Phone: __________________________________________________________
Relationship to child: ___________________________________________

Parent certification

I/We certify that all information given on this form is correct and accurate to the best of our knowledge. I/We will notify the provider if any information changes.

Parent or guardian 1 signature: __________________________________
Date: ____________________
Parent or guardian 2 signature: __________________________________
Date: ____________________

Provider admission record

Admission decision: ☐ Accepted ☐ Pending ☐ Declined
Date: ____________________
Provider notes: __________________________________________________

________________________________________________________________

Provider signature: ______________________________________________
Date: ____________________

Authorization for emergency medical care

I/We give Teida B. Edwards permission to call a doctor or emergency medical service and for a doctor, hospital, or medical service to provide emergency medical or surgical care for my child, ________________________________________________.

The childcare provider will make a conscientious effort to locate the parent or guardian and emergency contacts listed on this record before action is taken. If those contacts cannot be reached, treatment will not be delayed. I/We accept the expense of emergency transportation and medical or surgical treatment.

Parent or guardian signature: ____________________________________
Date: ____________________
Parent or guardian signature: ____________________________________
Date: ____________________