ࡱ> <>; bjbj >  !f=====lnnnnnn$S====ll=Q;q/X0{{{<{ :  APPLICATION FOR ENROLLMENT Childs Name: _____________________________________________ Surname First Initials Date of Birth: ___________________ Days of Care: _______________ Mother ___________________ Home Phone: _______________ Name Home Address: ____________________________________________________ Business Address: ____________________________________________________ Business Phone: ___________________ Cellular Phone: _______________ E-mail Address: ____________________________________________________ Father ___________________ Home Phone: ________________ Name Home Address: ____________________________________________________ Business Address: ____________________________________________________ Business Phone: ___________________ Cellular Phone: _______________ E-mail Address: ____________________________________________________ Authorized persons who may pick up my child in the case of an emergency: Name: _______________________ Home/ Cell Phone: __________________ Relationship: _________________ Business Phone: _____________________ Name: _______________________ Home/ Cell Phone: ___________________ Relationship: _________________ Business Phone: _____________________ Childs Physician: _________________________________________________ Address: _________________________________________________ Telephone: ___________________ Health Card #: ________________ Allergies: ___________________________________________________________ _______________________________________________________________________ _________________________________________________________________ include how the allergy usually manifests itself hives, skin rash Previous history of communicable diseases, conditions requiring medical attention? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Any special diet, rest or exercise requirements? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Any other related information that you feel we need to better understand your child? Favorite Activities, previous playgroup experiences, siblings __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Parent/Guardian Signatures: _________________________________________ _________________________________________ Admission Date:______________________ Discharge Date: ____________ Month/Day/Year Month/Date/Year Directors Initials: _____________ Date: _________________ ^z  < Z m r  I??i˽ܽܽܬܖ܈܄zf&h&Cph^5CJOJQJ\^JaJh^OJQJ^Jh^h)CJOJQJ^JaJh^CJaJh^CJOJQJ^JaJ h^6CJOJQJ]^JaJh^CJOJQJ^JaJ h^5CJOJQJ\^JaJh^CJOJQJ^JaJ)jh&Cph7 CJOJQJU^JaJ {| K L   Z r B C $a$gd&CpC   b c 8 9 u v I#$a$#?@6ij @ ^@ `<P&P:p9%/ =!"#`$`% DpWDd 2D  3 A"bXѬ3Xâo*֕DQnXѬ3Xâo*֕PNG  IHDRd/$PLTEkT׸H$lmnҳUƻų rYyzbŦg3utƴC{;wv]ʬgNmǼ+m |fr^e2qϯ~fˁĜoUc01ȷm>?wKL؁XYbHܽoWpxbKGDH cmPPJCmp0712HsXIDATx^\ wF*V{nKؕm*_ݙu{ֳn%!33?/WdEsjpp]J؜]9\W6gWUi઄ٕuU*asvp]J؜]9\W6gWUi઄ٕuU*a/ͮ?[wS({ݲMӴ' ջ*^޸jbge(* IK)[Fa)_qiT7z9z$x`gmF%\Lk`F;XR;^'XUoݮLx&bE\N (7rrԨQOo~Ti?<<eϨfZ6t2$`>2 u;ם9<r}8^>Ă8Cʻ+E?<%'!9N\]=<}[Zeyх ȪIJ#VyD7J[+:8 {>"?[SeTCo|ʇjm8rD4[`pG$jc4 0<29I0&^? /ZVԤwIs:q{0:UC WIյ4ĭThetDbpY.\sz'e{\*KtFCjj=P S\]K`&dTZCm0jŅ t$!evBnˋ&?,Hq*L$vtc*+7`"G͞mx5fBFu.rްcyÅx,,pZM X6nDe$$p)UipUDE 4[TN8\T[]I&h\IUrDq Ċa9\K*ʾdRS̘f1UA:sztfg3%u7ɦƎuuqD  Wa ܙc4Jiy|>W\ ԍ?b\vB51QMF'G3tVV!xh..[xAX^MY`G(ӱF~- H8\Dh$h9̎0 ~fT{|܊@u8&.p#rd32;k$G."=q5)PlJL uQӫa -DB6bYjsk.EF(C4e]rx}{X2 ExPk }{rbpr/qk2N7:҉V8Hʂ0DM,^XNk /wKIqLsUpQ_:V*l2r+3(N 2#Q*+T7(⑸ˋZiř*pHڡFZ,ehqh,2mc ֩좾Dm!G >qFuTBWdǟO^*nd+Q*n*Vg;Dj4-l!@{PZשpѤ肒 zk_Z$>}ЌibC"4*BA W[:RtJN=1:`At8 ^ 6'=.B'-jpDmSu/aSd-j;+DFڞ$\=R*괭X޿fFS84͓#ؕ<@ a[$#֑L2 P)WV!g6a:4Uvg.H\|‰jӨMն%xΠ`;y)'xpfAj"\ҐՁr<I ٤g}$Ĝm@t'!lO+ڏm&DLXэԒMQ<ubr;L$s:N7l{u@kQRKpu[(Yu\xP3vr253oܤDCFul1gCzld#%\)Om{QbY]Pܚ'zOmH؛0‰k]ip6֐`;$KxxCGJt!YBR\# cW2gs͝s.8il@zJm*TBgթ#~XrRE%. =Rņ7"^Yk b7eXHbmAm"k(WhHd#C0R\< iQFuIi1Ͱ}0i|%2GJtA$jU~dw/fbBi^1{sس= 4TCIy٥+=`|I z61RWzu9N7/#=JlK]GJtQMd.V;fX J%"XAѦRϯd|+d<=&۹Q-t"G7ф$WЈ,bIh?.K12 Ul߇xZvf@%8|mR6| Nipq?Btt6pAIQ-Mٛ J78֥\ %+v4GKta|}]Y6b LMJ/'EJ/&|EB,9Z$v;EYa k:Ob-pk0[ȟS$ByO.b?sEj^`W>s3T0)S:AT6Ou]]GHVCPmp]" ݼp^ݤ'YjpΘ˨ b(8KsdH1[&. 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