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Parent Registration

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Contact Information:
Child's Name:
Gender:
Child's Date of Birth
Mother's Name:
Mother's Home Telephone #:
Mother's Address:
Mother's Email:
Father's Name:
Father's Home Telephone:
Father's Address:
Father's Email:
Mother's Work Telephone #:
Mother's Employer:
Mother's Work Address:
Father's Work Telephone #:
Father's Employer:
Father's Work Address:
Mother's Cell/Pager #:
Father's Cell/Pager #:
Daycare Information:
Start Date of Daycare Required:
 Days Daycare is Required: Monday
 (check all that apply) Tuesday
  Wednesday
  Thursday
  Friday
Hours Required:
Languages Spoken at Home:
Child's School (if applicable):
How did you hear about Hopscotch?:
Child's Medical Information:


Child's Physician:
Physician's Telephone #:
Physician's Address:
List any known allergies:
List any medical conditions:
List any medications your child is taking:
Check off any communicable diseases that your child has had:
Chicken Pox
  Hepatitis A or B
  Measles
  Meningitis
  Mumps
  Pertussis (Whooping Cough)
Child's Personal Information:
List any pets at home:
Does anyone smoke at home?:
Do you have an established routine for your child?:
Does your child wear cloth or disposable diapers?:
List any previous daycare experience your child has had:
Generally describe your child's personally (e.g. likes, dislikes, etc.):
Does your child have a learning disability?:
If so, please describe:
Does your child have a good appetite?:
List any special foods/liquids that your child requires:
Does your child have any problems sleeping?:
Are there any special toys or blankets that your child likes to sleep with?:
Does your child have any fears?:
How do you calm your child down if he/she is upset?:
Does your child socially interact well with other children?:
Are there any specific concerns or circumstances for which we should be aware?:
What types of activities would you like your child to be occupied with while in daycare?:
Will you give consent to transporting your child in a licensed vehicle?:
Emergency Contacts:
Please provide two emergency contact names, if parents cannot be reached, and to whom your child may be released.
Contact Name #1 & Relationship to Child:
Daytime Telephone # for Contact Name #1:
Address for Contact Name #1:
Contact Name #2 & Relationship to Child:
Daytime Telephone # for Contact Name #2:
Address for Contact Name #2:

I certify that the information I have supplied on this application is correct and truthful.  Hopscotch will contact you shortly to discuss your needs and answer your questions.  Upon acceptance of the registration, you will be entitled to interviews with Providers.  Your submittal of this application indicates that you understand that you cannot make private arrangements during interviews with potential Providers or you cannot provide the Provider's contact information to any other persons. 

Hopscotch Home Daycare Agency
Tel: 289.466.1111*
Email: info@hopscotchdaycare.com
Facebook: www.facebook.com/hopscotchdaycare



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