St. Louis Child Care Application

Care Needed By:

Child's Information

Child's Full Name:

Child's Gender: Male
Female

Child's Date of Birth:

Child's Address:

Child's Mailing Address: If different from their physical address

Parent's Marital Status: Single
Married

1st. Parent/Guardian Information

The person you list as the "1st Parent" will be the one that is contacted first for any emergency.

What is the best method to contact this person?:

Parent/Guardian Name:

Address:

Mailing Address: If different from address

Email:

Cell Phone:

Do you text?: Yes
No

Home Phone:

Place of Employment:

Employment Address:

Employment Mailing Address: If different from Employment Address

Work Phone:

2nd Parent/Guardian Information

2nd Parent/Guardian Name:

Address: If different from 1st Parent

Mailing Address: If different

Email:

Cell Phone: If different from above

Do you text?: Yes
No

Home Phone: If different from above

Place of Employment:

Employment Address:

Employment Mailing Address: If different from Employment Address

Work Phone:

Emergency Numbers

To be contacted in case parent(s) cannot be reached in an emergency

Name 1:

Relationship 1:

Phone 1:

Street Address 1:

Name 2:

Relationship 2:

Phone 2:

Street Address 2:

Names of People Not Listed Above

who are able to remove the child(ren) from the Center

Other Names:

Child's Family Information

Primary Language:

Religion:

Preferred Language for Communication:

US Census Category: White/Caucasian
Black/African American
Native American/Alaskan
Hispanic/Latino
Asian
Other

Childcare Needs

Type of Childcare: Full Time
Part Time

Childcare Hours Needed: How many hours per day needed

Which Days?: Monday
Tuesday
Wednesday
Thursday
Friday
Doesn't Matter

Child's Health Information

Has your child had any serious illnesses?: Yes
No

If yes, what were they and when did he/she have them?:

How is your child’s present general health?:

Who is your child’s physician?:

Physician's phone number:

Physician's address:

Last tetanus shot date:

Name of medical insurance plan:

Insurance ID#:

Does your child have a dentist?: Yes
No

Condition of your child’s teeth?:

Who is your child’s dentist?:

Dentist's phone number:

Dentist address:

Does your child have a history of: allergies, ear infections, frequent sore throats, asthma, seizures, serious illnesses or any other special needs that we should be aware of?:

If yes, please list history:

Toilet Habits

Is your child independent?: Yes
No

If not, to what extent does he/she need assistance?:

Other Information

Has your child ever been to nursery school or childcare center?: Yes
No

Where?:

When (how long)?:

Has your child ever been screened/evaluated by CDS or any other Early Intervention System?: Yes
No

If yes, please explain: Copies of evaluations or Individual Family Service Plan may be required prior to enrollment

What would you like your child to experience at St. Louis?:

Is your child especially good at anything like music, art, performing for others, leading other children, engaging in physical activities?:

Do you have any concerns about your child being in group care?: These may include a short attention span, difficulty sitting, temper tantrums, difficulty waiting for a turn, hitting, screaming, etc. If yes, please explain.

Is there any information not yet mentioned that will help us understand your child better?:

Income Information: Private Fee Paying Parent
Receiving Aspire (May Receive/Have an Aspire Child Care Voucher)
Have A DHHS (State) Child Care Voucher
Check all that apply

Found out about your center by:

Consent & Signature

I hereby give my consent, in the event of a medical emergency when I cannot be contacted, for child care staff to obtain whatever treatment may be deemed necessary for:

Child name *:

Child date of birth *:

This authorization includes my consent for the above named child to receive treatment by a physician in any hospital emergency department.

I hereby give my authorization for emergency medical treatment as outlined above.

Parent/Guardian Signature *: Enter your name in place of a signature

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