CAROUSEL KIDS

Enrollment Application and Agreement

Entrance Date____________________________

Withdrawal Date___________________________

Childs Name__________________________________Sex_____Age__________Date of Birth____________

Home Address (Street)_____________________________________________________________________
City__________________________________________State________________Zip____________________
Home Phone Number__________________________________
Fathers Name_________________________________Home Phone Number__________________________
Fathers Home Address (if different from childs) Street____________________________________________
City______________________________________State__________________Zip______________________
Fathers Place of Employment__________________________________Work Phone____________________
Employers Street Address_______________________________City_____________State______Zip_______
Mothers Name________________________________Home Phone Number__________________________
Mothers Home Address (if different from childs) Street____________________________________________
City______________________________________State__________________Zip______________________
Mothers Place of Employment__________________________________Work Phone___________________
Employers Street Address_______________________________City_____________State______Zip_______
Childs Living Arrangements: (check one) ( ) Both Parents ( ) Mother ( ) Father ( ) Other
Childs Legal Guardian(s):

(check one) ( ) Both Parents ( ) Mother ( ) Father ( ) Other

The child may be released to the person(s) signing this agreement or to the following:
*Name____________________________________Address________________________________________
(Street-City-State-Zip)

Telephone Number________________________________Relationship to Child________________________

Relationship to Parent(s) or Guardian__________________________________________________________
Other Identifying Information (if any)___________________________________________________________
*Name____________________________________Address________________________________________
(Street-City-State-Zip)

Telephone Number________________________________Relationship to Child________________________

Relationship to Parent(s) or Guardian__________________________________________________________
Other Identifying Information (if any)___________________________________________________________

Persons to contact in the case of emergency when parent or guardian cannot be reached:
Name_______________________________________Telephone Number_____________________________
Name_______________________________________Telephone Number_____________________________
Name_______________________________________Telephone Number_____________________________
Name of Public or Private School child attends, if any:_____________________________________________
Childs Doctor or Clinic Name________________________________________________________________
Doctor/Clinic Telephone Number____________________________________
My child has the following special needs________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
The following accommodation(s) may be required to most effectively meet my childs needs while attending:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
My child is currently on medication(s) prescribed for long-term continuous use and/or has the following preexisting illness, allergies, or health concerns:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

EMERGENCY MEDICAL AUTHORIZATION

Should (childs name)______________________________________Date of Birth______________________
Suffer an injury or illness while in the care of Carousel Kids, Inc. and the center is unable to contact me (us)
immediately, it shall be authorized to secure such medical attention and care for the child as may be
necessary. I (we) shall assume responsibility for payment of services.

Parent/Guardian:_________________________________________________________________________
Signature
Date:____________________________________

Director/In-Charge Staff:___________________________________________________________________
Signature
Date:____________________________________

Parental Agreements with Child Care Facility

Carousel Kids, Inc. agrees to provide child care for _______________________________________________________

(Name of Child)
on ___________________________________from____________am to____________pm.
(Days of Week)
Check here if only before/after school care provided.
My child will participate in the following meal plan (circle applicable meals and snacks):
Breakfast
Morning Snack
Lunch
Afternoon Snack
I agree to pay the total weekly fee of $____________ on Friday or Monday for the upcoming week.
Before any medication is dispensed to my child, I will provide a written authorization, which includes: date, name of child,
name of medication, prescription number, dosages, date and time of day medication is to be given. Medicine will be in the
original container with my childs name marked on it.
My child will not be allowed to enter or leave the facility without being escorted by the parent(s), person authorized by
parent(s), or facility personnel.
I acknowledge it is my responsibility to keep my childs records current to reflect any significant changes as they occur,
e.g., telephone numbers, work location, emergency contacts, childs physician, childs health status, infant feeding plans
and immunization records, etc.
The facility agrees to keep me informed of any incidents, including illnesses, injuries, adverse reactions to medications,
etc., which include my child.
Carousel Kids, Inc. agrees to obtain written authorization from me before my child participates in routine transportation,
field trips, special activities away from the facility, and water-related activities occurring in water that is more than two (2)
feet deep.
I authorize Carousel Kids, Inc. to obtain emergency medical care for my child when I am not available.
I have received a copy and agree to abide by the policies and procedures of Carousel Kids, Inc.
I understand that Carousel Kids, Inc. will advise me of my childs progress and issues relating to my childs care as well
as any individual practices concerning my childs special needs. I also understand that my participation is encouraged in
facility activities.

Signed:_______________________________________________________Date:_______________________________
(Parent/Guardian)
Signed:_______________________________________________________Date:_______________________________
(Director/In-Charge Staff)