Cam's Enrollment Application 812-940-2267

What is the name of the child? *

What is the child's date of birth? *

What is the parent/guardian's name? *

What is the parent/guardian's contact number? *

What is the parent/guardian's email address? *

What is the preferred start date for childcare? *

Please provide name and number of an emergency contact. *

Please provide name & number of your Pediatrician or Primary Care Physician. *

Please provide name and number of your child's Dentist. *

Our hours of operation are Monday-Friday 8:00 AM-4:30 PM, will this schedule work for you? *

Yes, these hours work for me.

No, these hours will not work for me.

Our facility does not provide lunch only A.M. Breakfast and P.M. Snack. Lunch must be provided by the parent. Will you have a problem providing a daily lunch for your child? *

No, I can provide a lunch for my child daily.

Yes, I will have a problem providing a daily lunch.

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

Is the child up to date on all vaccinations? *

Yes

Not sure

Please attach copy of Immunization Shot Record

Is there any additional information you would like to provide about the child or family? *

By signing this form, I acknowledge that I have answered all questions to the best of my ability. *

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