Child Enrollment

Child Information
Name*
First Middle Last
Date of Birth*
Month
Day
Year
Age*

Specify whether it is in month or years.
Gender*
Potential Start Date (if known)
MM slash DD slash YYYY
Address*
Street Address City State / Province / Region ZIP / Postal Code
Which days will your child attend?*
- 5 Days
- 3 Days
- 2 Days
Giving Tree does not offer part-time for children under 3 years old.
Preferred Days
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
Part-Time based on availability
Does your child have any known allergies? If yes, please explain.*

After School Children Only (Optional to fill out)
Name of School
Grade Level
Rate
- Traditional ($100)
- One ($120)
Parent/Guardian Signature
First Last
Date
Month
Day
Year
My signature authorizes Giving Tree Child Development Center to drop off/pickup my child to/from school.
I agree
My signature authorizes Giving Tree Child Development Center to drop off/pickup my child to/from school.

Family Information
Family Information #1
Father/Guardian's Name
First Last
Primary Phone Number
Secondary Phone Number
Email
Best Way to Contact
- Phone
- Email
Address
Street Address City State / Province / Region ZIP / Postal Code
Employer Name
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Family Information #2
Mother/Guardian's Name
First Last
Primary Phone Number
Secondary Phone Number
Email
Best Way to Contact
- Phone
- Email
Address
Street Address City State / Province / Region ZIP / Postal Code
Employer Name
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Emergency Care Information
Medical Doctor's Name
Practice Name
Phone
Insurance Carrier
Policy Number
Hospital Preference
In the unlikely event of an emergency and/or late pick-up (6:15PM) where neither parent/guardian are reachable, please list the names, relationship, and contact information of three other people which whom we may contact and/or release your child to.
Emergency Contact #1
Name
Name
Relationship to Child
Primary Phone Number
Secondary Phone Number
Emergency Contact #2
Name
Name
Relationship to Child
Primary Phone Number
Secondary Phone Number
Emergency Contact #3
Name
Name
Relationship to Child
Primary Phone Number
Secondary Phone Number
Emergency Treatment and Transportation

I hereby give permission to Giving Tree Child Development Center licensed by the Department of Social Services to secure emergency medical, dental, and/or emergency surgical treatment and to provide emergency transportation for above named minor child while in care.

*** Children are ONLY released to their parents unless otherwise arranged with office personal. All authorized pick-up persons must present a valid photo ID to office personal before children are released.***
Parent Signature
Date
Month
Day
Year
Consent*
I agree
I hereby give permission to Giving Tree Child Development Center licensed by the Department of Social Services to secure emergency medical, dental,
and/or emergency surgical treatment and to provide emergency transportation for above named minor child while in care.

*** Children are ONLY released to their parents unless otherwise arranged with office personal. All authorized pick-up persons must present a valid
photo ID to office personal before children are released.***

Giving Tree

Step 1 of 4

Child Information

After School Children Only (Optional to fill out)

Family Information

Family Information #1

Family Information #2

Emergency Care Information

Emergency Contact #1

Emergency Contact #2

Emergency Contact #3

Emergency Treatment and Transportation

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