FOR OFFICE USE ONLY

Date of Contact: __/__/__                                                                                                                                               Items Completed: Reg. Fee __ App. __

Room: Infant Toddler Preschool                                                                                                                                     Immunizations __ Emergency __

New Child: No Yes                                                                                                                                                          Permission __ Verify MTI __ Schedule _

MTI Community Other _________                                                                                                                                 Payment Agreement __ Food Prog. __

Date Enrollment Complete __/__/__                                                                                                                               Policy Checklist __ CCA Verification __

 

                                                                                        MITCHELL TECHNICAL INSTITUTE

                                                                            CHILD DEVELOPMENT CENTER

                                                                       Enrollment Application

 

 

Start Date __________________________________________________________________________

 

Family Name _______________________________________________________________________

 

Address ____________________________________________________________________________

 

Phone ______________________________________________________________________________

__________________________________________________________________________________________

 

Children: For whom child care is requested

 

 

          First Name               Middle Name           Nick Name              Sex         Age        Birth Date

 

1.  _______________     _______________     _______________     _____     _____     ______________

 

2.  _______________     _______________     _______________     _____     _____     ______________

 

3.  _______________     _______________     _______________     _____     _____     ______________

 

4.  _______________     _______________     _______________     _____     _____     ______________

 

 

                                                                         Married                  Divorced            Single

Parent’s Marital Status:                                    _______                  ________           ______

                                                                                                          How Long?

Remarks: (custody/visiting arrangement)

 

 

 

 

Mother: ________________________________             Place of Employment ____________________

                          (or legal guardian)                                   Telephone Number ______________________

                                                                                           Work Hours ___________________________­

 

Father: _________________________________             Place of Employment ____________________

                           (or legal guardian)                                  Telephone Number ______________________

                                                                                           Work Hours ____________________________

 

If adopted: Date ______________________  Has child been informed? __________________________

 

 

 

 

 

 

                                                                          MITCHELL TECHNICAL INSTITUTE

                                                                 CHILD DEVELOPMENT CENTER

                                                                                  Emergency Authorization Form

  

 

 

 

Child’s Name: ______________________________  Home Phone: ___________________________________

 

Birth Date: __________________________  Home Address: ________________________________________

 

Weight: _____________ Height: _______________ Child’s Social Security #: __________________________

 

Mother’s Name: _____________________________ Father’s Name: _________________________________

 

Employed at: ________________________________ Employed at: ___________________________________

 

Business Phone: ______________________________ Business Phone: ________________________________

 

Allergies: _________________________________________________________________________________

 

Friend or relatives to call, if you cannot be reached:

 

1.  Name: _________________________________  Relationship: ____________________________________

 

     Phone: _________________________________  or _____________________________________________

 

2.  Name: _________________________________  Relationship: ____________________________________

 

     Phone: _________________________________ or  _____________________________________________

 

Physician to be called in an emergency:

 

1.  _______________________________________  Phone: _________________ or _____________________

 

2.  _______________________________________  Phone: _________________ or _____________________

 

 

I hereby grant permission for the Assistant Director or supervisory staff person to take whatever steps may be necessary to obtain emergency medical care if warranted.  These steps may include, but are not limited to, the following:

 

  1. Attempt to contact the parent or guardian.
  2. Attempt to contact the child’s physician.
  3. Attempt to contact the parent or guardian through any of the persons listed on this sheet you have completed.
  4. Call another physician.
  5. Call an ambulance.
  6. Have the child taken to an emergency room at the nearest hospital in the company of a CDC staff member.
  7. Any expenses incurred will be the responsibility of the parent or legal guardian.

 

Signature of parent or legal guardian _________________________________ Date: _____________________

 

 

                                                                   MITCHELL TECHNICAL INSTITUTE

                                                                        CHILD DEVELOPMENT CENTER

                                                                          Parent Permission Form

 

 

 

 

 

YES                 NO

 

____                ____            I hereby grant permission for my child to leave the CDC premises under the                        

                                            supervision of a staff member for neighborhood walks.

 

____                ____            I hereby grant permission for my child to join the class in any field trip they may

                                            take.  I understand I will be notified in regard to the place, date and time prior to

                                            the activity taking place.

 

____                ____            I hereby grant permission for my child’s name and/or picture to be used in

                                            publicity connected with the Center.

 

____                ____            I understand that the Center is a training site for the Early Childhood Administration

                                            Programs, thus the students will be working with and/or observing children under

                                            the discretion of the instructor/site supervisor.

 

 

I authorize the following persons to take my child from the CDC and agree to written or oral permission if my child is to be released to anyone not listed below.

 

Name                                                                                Relationship to Child

 

______________________________________              __________________________________________

 

______________________________________              __________________________________________

 

 

The following persons are not authorized to take my child from the CDC.  Legal documentation, e.g. copies of the birth certificate, custody papers, etc., may be required.

 

Name                                                                                  Relationship to Child

 

______________________________________                _________________________________________

 

______________________________________                _________________________________________

 

 

 

Signature of parent or legal guardian ___________________________________ Date ____________________