Mac's Enrollment Application

Child's name (first & last)? *

What is your child's Birthdate? *

Child's Gender *

Mother's Full Name *

Mother's Phone Number *

Mother's Home Address *

Mother's Employer Name & Address *

Mother's Employer Phone Number. *

Father's Full Name *

Father's Phone Number *

Father's Home Address *

What is the name of your child's physician? *

Father's Employer Name & Address *

Person/s with whom the child lives: *

Child's Physician *

Child's Physician Phone Number *

Preferred Hospital: *

Preferred Hospital Phone Number: *

Emergency Contact Name: *

Emergency Contact Phone Number: *

Emergency Contact Name: *

Emergency Contact Phone Number: *

Emergency Contact Name: *

Emergency Contact Phone Number: *

Does your child have any allergies or medical conditions we should be aware of? *

Yes

If yes, please list any allergies or medical conditions:

Is your child up-to-date on all required vaccinations? *

Yes

Not sure

Please attach updated Immunization Record. MyChart Screenshots are not acceptable, record must be signed and dated. (Your child cannot start without this document) *

Does your child have any dietary restriction? *

Yes

Not sure

If yes, please list dietary restrictions:

Does your child have any special needs? *

Yes

Not sure

If yes, please list special needs:

Does your child have any special services? *

Yes

Not sure

If yes, please list special services:

Will your child receive services at the facility. *

Yes

Not sure

If yes, please list what special services will need to be done at the facility:

Please provide a list of any medications your child is currently taking: *

Is your child currently enrolled in any other childcare programs? *

Yes

We have a $50 Enrollment fee per child or $75 per family. Please list Name on Card and your 16 Digit Credit Card Number & Expiration Date. Enrollment fee will not be processed until your enrollment is approved. *

If yes, please provide the name and contact information for the program(s):

My child has permission to be released to the following individuals or transportation services in addition to the emergency contact person listed above. (Please notify all individuals that they may be asked to show proof of identity). Please list contacts and relationship below.

TRANSPORTATION I agree that my child may take off premises nature walks if weather permits. I acknowledge that my child may be transported by authorized Mac's Childcare vehicles driven by authorized staff 21 years of age or older in the event of a field trip, to and from school and home and/or in the event of emergency . *

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I acknowledge that I have been informed that there may be living things in my child's classroom such as pets and plants on the premises. I agree to be responsible for any additional cost associated with the collection of any fees for materials or late fees. I understand that my child will be dismissed if I do not provide the center with a current immunization certificate. I authorize this program and their representatives to give emergency medical treatment for my child if necessary. *

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