Child Care Enrollment

Use of form: Use of this form is mandatory for Family Child Care Centers to comply with DCF 250.04(6)(a)1. Failure to comply may result in issuance of a noncompliance statement. This form may also be used by Group Child Care Centers and Day Camps to comply with DCF 251.04(6)(a)1. and DCF 252.41(4)(a)1. respectively. Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m), Wisconsin Statutes].
Instructions: The parent / guardian shall fill out the form completely, sign it and submit it to the center prior to the child's first day of attendance. Information on this form shall be kept current. When enrolling a child under two years of age, a completed Intake for Child Under 2 Years form must also be on file prior to the child's first day of attendance.

CHILD INFORMATION

Name*

First Last

Birthdate*

First Day of Attendance*

PARENT OR GUARDIAN

All parents / guardians are permitted to visit during center hours and are allowed to pick up the child unless access is prohibited or restricted by a court order. Attach court order, if any. If the child resides at multiple locations, the department recommends the provider obtain and attach a schedule.

First Parent's Name*

First Last

Relationship to Child*

Home / Cell Phone No.*

Email Address Where Reachable While Child is in Care*

Home Address*

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

Does child reside at this location?*

Yes

Place of Employment*

Work Phone No.*

Second Parent's Name

First Last

Relationship to Child

Home / Cell Phone No.

Email Address Where Reachable While Child is in Care

Home Address

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

Does child reside at this location?

Yes

Place of Employment

Work Phone No.

AUTHORIZED PERSONS

Is there anyone, other than the parents / guardians, authorized to pick up the child or accept the child if dropped off?*

Yes

Authorized Person's Name

First Last

Relationship to Child

Home / Cell Phone No.

Email Address Where Reachable While Child is in Care

Place of Employment

Work Phone No.

Second Authorized Person's Name

First Last

Relationship to Child

Home / Cell Phone No.

Email Address Where Reachable While Child is in Care

Place of Employment

Work Phone No.

EMERGENCY CONTACT

The person to be notified in an emergency when parents / guardians cannot be reached.

This person is authorized to pick up the child.*

Yes

Name*

First Last

Relationship to Child*

Home / Cell Phone No.*

Email Address Where Reachable While Child is in Care*

Place of Employment*

Work Phone No.*

PHYSICIAN OR MEDICAL FACILITY

Name*

Address*

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

Telephone Number*

AUTHORIZATIONS

I hereby give my consent for emergency medical care or treatment to be used only if I cannot be reached immediately.*

Yes

I have had an opportunity to review the policies of this child care center and a summary of the Wisconsin Rules for Licensing Child Care Centers.*

Yes

I give permission for my child to participate in any of the following activities during operating hours:*

Transported Field Trips

Walking Field Trips

None

I have been informed of the number of pets in the center and their degree of contact with the enrolled children. Note: If pets are added after a child is enrolled, parents shall be notified in writing prior to the pet's addition to the center.*

Yes

SIGNATURE – Parent or Guardian

Name*

Date Signed*