KIDS LANDING, INC
Date entered in DB_______
Initials of Enterer_______
Enrollment Form
Application date: _______________
1 Child’s Name ___________________________________________________________ DOB ____/___/____
Does your child have any dietary restrictions / known food allergies, or any other allergies? If yes, please explain ______________________________________
Is your child in diapers/ training/ trained? (Please circle one)
Will your child rest on a mat? ______________________________ Does your child require a high chair? _________________________
Does your child have any special needs or behavioral problems we should be aware of? ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
Briefly describe Child’s personality, likes and dislikes____________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
2 Child’s Name ____________________________________________________ DOB ____/___/____
Does your child have any dietary restrictions / known food allergies, or any other allergies? If yes, please explain ______________________________________
Is your child in diapers/ training/ trained? (Please circle one)
Will your child rest on a mat? ______________________________ Does your child require a high chair? _________________________
Does your child have any special needs or behavioral problems we should be aware of? ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
Briefly describe Child’s personality, likes and dislikes____________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
3 Child’s Name ________________________________________________________ DOB ____/___/____
Does your child have any dietary restrictions / known food allergies, or any other allergies? If yes, please explain ______________________________________
Is your child in diapers/ training/ trained? (Please circle one)
Will your child rest on a mat? ______________________________ Does your child require a high chair? _________________________
Does your child have any special needs or behavioral problems we should be aware of? ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
Briefly describe Child’s personality, likes and dislikes____________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
4th Child’s Name ________________________________________________________________ DOB ____/___/____
Does your child have any dietary restrictions / known food allergies? If yes, please explain._________________________________________________________
Is your child in diapers/ training/ trained? (Please circle one)
Will your child rest on a mat? ______________________________ Does your child require a high chair? _________________________
Does your child have any special needs or behavioral problems we should be aware of? ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
Briefly describe Child’s personality, likes and dislikes___________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
PARENT/GUARDIAN INFORMATION
Name _______________________________________________________________
Address ___________________________City ______________ Zip ____________
Home Phone__________________________
Additional contact information: Work__________________ Cell _______________
Email________________________________
Who may we contact in case of an emergency if the parents/guardian cannot be reached? (Please list three additional persons below).
Name________________________________________________________________ Phone_____________________________________________
Is this person authorized to pick up your child/children? YES / NO
Name________________________________________________________________ Phone_____________________________________________
Is this person authorized to pick up your child/children? YES / NO
Name________________________________________________________________ Phone______________________________________________
Is this person authorized to pick up your child/children? YES / NO
PLEASE NOTIFY KIDS LANDING, INC. IMMEDIATELY IF ANY OF THE ABOVE INFORMATION CHANGES
I have read and understand the policies and guidelines presented by Kids Landing Inc and will abide by all guidelines and rules. I understand that while all reasonable and appropriate measures are taken to secure the safety and welfare of my child, that accidents may occur, and that in such an event, I will not hold Kids Landing Inc. or it officers liable for such occurrence.
Signature of Parent/Guardian _____________________________________________________ Date____________________________
Medical Release
In the event that I cannot be reached to make arrangements for emergency
medical attention, I authorize Kids Landing, Inc. to contact:
Physician’s Name ________________________________________________________________ Phone_________________________
Address________________________________________________________________________
Dentist’s Name __________________________________________________________________ Phone__________________________
Address________________________________________________________________________
And if necessary, I give permission for my child to be taken to the following clinic or hospital: _________________________________________________
I further give consent for any necessary emergency treatment when my child is in the care of physician and/or hospital/clinic
Signature of Parent/Guardian ____________________ Date________________
