Child Care Enrollment Form - Missouri
MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
SECTION FOR CHILD CARE REGULATION / BUREAU COMMUNITY FOOD & NUTRITION ASSISTANCE
CHILD CARE ENROLLMENT FORM
MON
TUES
WED
THURS
FRI
SAT
SUN
PLEASE ALSO COMPLETE PAGE 2.
CACFP REQUIREMENT
GENDER
BIRTHDATE
IDENTIFYING INFORMATION
MOTHER'S/GUARDIAN'S NAME
HOME PHONE
AM PM
AM PM
CELL PHONE
AM PM
AM PM
WHAT TIME DOES YOUR
CHILD USUALLY ARRIVE
EACH DAY?
CIRCLE AM OR PM.
CHILD'S PROJECTED ATTENDANCE SCHEDULE AND ANY VARIATIONS EXPECTED
AM PM
ADDRESS (STREET, CITY, STATE, ZIP)
COMMENTS ON CHILD'S DEVELOPMENT
EMPLOYER/SCHOOL ADDRESS (STREET, CITY, STATE, ZIP)
WORK PHONE
WHAT TIME DOES YOUR CHILD
USUALLY LEAVE EACH DAY?
CIRCLE AM OR PM.
WRITE ANY COMMENTS, CHANGES OR
VARIATIONS IN USUAL ATTENDANCE IN THIS
SECTION INCLUDING SHIFT CHANGES.
CHECK HERE WHAT DAYS
THE CHILD WILL ATTEND.
WILL CHILD ATTEND:
Full Time or Part Time
AM PM
NAME
WORK/SCHOOL SCHEDULE
AM PM
AM PM
AM PM
AM PM
AM PM
YES NO
HOW IS CHILD RELATED TO CHILD CARE PROVIDER?
AM PM
AM PM
E-MAIL
ADDRESS (STREET, CITY, STATE, ZIP) OR CHECK IF SAME AS ABOVE
ADDRESS (STREET, CITY, STATE, ZIP)
PHONE NUMBERS
(CELL, WORK, HOME)
EMPLOYER/SCHOOL ADDRESS (STREET, CITY, STATE, ZIP)
WORK PHONE
EMPLOYER OR SCHOOL ATTEND
ADDRESS (STREET, CITY, STATE, ZIP)
RELATIONSHIP TO CHILD
HOME PHONE
CHILD'S NAME
(NOTE CHILD'S PERSONAL DEVELOPMENT, BEHAVIOR, PATTERNS, HABITS, AND INDVIDUAL NEEDS)
RELATED CHILD
EMPLOYER OR SCHOOL ATTEND
WORK/SCHOOL SCHEDULE
CELL PHONE
PHONE NUMBERS
(CELL, WORK, HOME)
E-MAIL
ADDRESS (STREET, CITY, STATE, ZIP) OR CHECK IF SAME AS ABOVE
AM PM
DISCHARGE DATE
ADMISSION DATE
FACILITY/PROVIDER NAME
NAME
RELATIONSHIP TO CHILD
EMERGENCY CONTACT AND PERSONS AUTHORIZED TO TAKE CHILD FROM FACILITY
(OTHER THAN PARENT) AT LEAST ONE EMERGENCY CONTACT IS REQUIRED.
FATHER'S/GUARDIAN'S NAME
MO 580-2994 (1-12) SCCR/CACFP PAGE 1
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