Enrollment Form

Enrollment Form

Christina Weiss’s Home Daycare

Cedar Street

Spring City, Pennsylvania 19475

610-960-2088

Child’s Name: _________________________Date of Enrollment____________

Age: _______________ Date of Birth: __________________________________

Child’s Name: _________________________Date of Enrollment____________

Age: _______________ Date of Birth: __________________________________

Home Address: ___________________________________________________

City/State/Zip Code: ________________________________________________

Home Phone: _____________________________________________________

Mother’s Name: ___________________________________________________

Address (if different): _______________________________________________

Mother’s Place of Employment: _______________________________________

Work Address: ____________________________________________________

City/State/Zip Code: ________________________________________________

Work Phone: ______________________ Cell Phone: _____________________

Father’s Name: ___________________________________________________

Address (if different): _______________________________________________

Father’s Place of Employment: _______________________________________

Work Address: ____________________________________________________

City/State/Zip Code: ________________________________________________

Work Phone: _______________________ Cell Phone: ____________________

Emergency Contacts:

Name: __________________________________ Phone: __________________

Health Information:

Pediatrician: ______________________________Phone: __________________

Hospital: _________________________________________________________

Insurance: _____________________________Policy #: __________________

Special Care Instructions: ___________________________________________

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