HTML Preview Daycare Application Form page number 1.
Family Child Care Admission and Arrangements
PLEASE PRINT. Complete one form for each child in care. This form must be kept on file at the family child care home. Please Note: Pursuant to
MN Rules. 9502.0405, subpart 4, the provider shall obtain the required information for each child prior to admission.
The licensed child care provider completes items 1, 8, & 9 prior to the parent/guardian completing the rest of the form. Both parties sign the form when completed.
The information requested will be maintained in a private manner and will not be released to anyone other than the licensing consultant without your prior written
approval.
1. NAME OF CHILD CARE PROVIDER(S) (LAST, FIRST, MIDDLE)
2. CHILD’S NAME (LAST, FIRST, MIDDLE)
ADDRESS
CHILD’S DATE OF BIRTH
CHILD’S AGE
NAME OF SUPERVISING AGENCY
TELEPHONE
3. DATE ENROLLED IN CARE
4. PARENT INFORMATION
PARENT/GUARDIAN
PARENT/GUARDIAN
NAME
PLACE OF EMPLOYMENT
ADDRESS OF EMPLOYMENT
WORK TELEPHONE
HOME ADDRESS
CONTACT NUMBERS
HOME PHONE
CELL PHONE
HOME PHONE
CELL PHONE
5. RESPONSIBLE FRIEND/RELATIVE TO CALL IF PARENTS CANNOT
BE REACHED
6. NAMES OF ALL PERSONS AUTHORIZED TO REMOVE THE
CHILD FROM THE HOME
NAME
ADDRESS
TELEPHONE
RELATIONSHIP
7. EMERGENCY CONTACT INFORMATION FOR CHILD
HOSPITAL TO BE USED FOR EMERGENCIES
PHYSICIAN’S NAME
ADDRESS
TELEPHONE
CITY, STATE, ZIP CODE
NAME OF PARENT’S MEDICAL INSURANCE COMPANY
CONTRACT #
IF UNAVAILABLE, ANOTHER LICENSED PHYSICIAN MAY TREAT MY CHILD YES NO
DENTIST’S NAME
ADDRESS
TELEPHONE
CITY, STATE, ZIP CODE
NAME OF PARENT’S DENTAL INSURANCE COMPANY
CONTRACT #
IF UNAVAILABLE, ANOTHER LICENSED DENTIST MAY TREAT MY CHILD YES NO
8. ARRANGEMENTS
FINANCIAL ARRANGEMENTS
SERVICES PROVIDED (INCLUDING DAYS, HOURS, MEALS ETC.)
SPECIAL CONDITIONS (SPECIAL DIET, SPECIAL NEEDS, ALLERGIES)
9. LIABILITY INSURANCE NOTIFICATION:
Pursuant to 245A.152 (a) A license holder must provide a written notice to all parents or guardians of all children to be accepted for care prior to
admission stating whether the license holder has liability insurance. This notice may be incorporated into and provided on the admission form
used by the license holder. Check one below
I do have liability insurance. A current certificate of coverage of insurance is available for inspection to all parents/guardians of children receiving
services and to all parents seeking services from the family child care program. My policy will expire on (month/day/year) _________________________.
I do not have liability insurance.
10. PERMISSIONS
AUTHORIZATION IS HEREBY GIVEN TO THE CHILD CARE PROVIDER AS NAMED IN ITEM 1 ABOVE, TO OBTAIN EMERGENCY
MEDICAL CARE OR TREATMENT IN THE EVENT OF AN EMERGENCY
YES NO
AUTHORIZATION IS HEREBY GIVEN TO THE CHILD CARE PROVIDER AS NAMED IN ITEM 1 ABOVE, TO PROVIDE
TRANSPORTATION TO MY CHILD
YES NO
AUTHORIZATION: We the undersigned hereby agree to abide by the arrangements and authorizations so stated above. We have discussed the information
required in the rule part 9502.0405.
SIGNATURE OF CHILD CARE PROVIDER
DATE
SIGNATURE OF PARENT/ GUARDIAN
DATE
November 2013