Around the Clock Childcare LTD Enrollment Form

Entrance Date: _________________________ Withdrawal Date: _____________________

Child's Name: ______________________________________Sex:____ Age____ DOB_____________
Home Street Address: _________________________________________________________________
City_______________________________ State_____________ ZIP___________________________
Home Phone Number____________________________ School Attending: ______________________
MOTHER'S INFORMATION
Name____________________________________ Home Phone Number: _______________________
Home Street Address: _________________________________________________________________
City: ____________________________________ State____________________ Zip_______________
Place of Employment __________________________________ Work Phone_____________________
Employer's Address __________________________________ City/State/Zip_____________________
FATHER'S INFORMATION
Name: ______________________________________Home Phone Number: ___________________
Home Street Address: _______________________________________________________________
City_________________________________State_______________Zip_______________________
Place of Employment _________________________________ Work Phone____________________
Employer's Address_____________________________City/State/Zip________________________
Child's Living Arrangements :(

) Both Parents ( ) Mother ( ) Father ( ) Other

Child's Legal Guardians: ( ) Both Parents ( ) Mother ( ) Father ( ) Other

Around The Clock Childcare Ltd | 123 Loving Care Lane, Douglasville Ga 30162

*My child will be dropped off at ______ and picked up at _______Mon, Tues, Wed, Thurs, and Fri.
*I understand that I am not allowed to change my hours at all unless I get permission from the Director.
*My rate is $__________ and is due every Friday. My child will not be allowed to attend on Monday if
the fee is not paid on Friday by midnight. The Center will not run balances. Weekly rates are based on
Monday Friday only.
*If I have a varying schedule, I understand that I have to turn a schedule in every Friday by midnight. I
am not allowed to alter this schedule after it has been submitted without approval from the Director.
*If my child is on CAPS, I understand that my children are only covered a certain amount of hours.
Please check with the Director to find out what is covered.
Night Care begins 11pm to 8am.
X______________________________________________________Date______________________
The child may be released to the person(s) signing this agreement or to
The following emergency contacts:
Name: __________________________________ Phone Number______________________________
Street Address______________________________________________________________________
City/State/Zip_______________________________________________________________________
Relationship to Child___________________ Relationship to Parent(s) _________________________
Name: __________________________________ Phone Number______________________________
Street Address______________________________________________________________________
City/State/Zip_______________________________________________________________________
Relationship to Child___________________ Relationship to Parent(s) _________________________
Name: __________________________________ Phone Number______________________________
Street Address______________________________________________________________________
City/State/Zip_______________________________________________________________________
Relationship to Child___________________ Relationship to Parent(s) _________________________

Around The Clock Childcare Ltd | 123 Loving Care Lane, Douglasville Ga 30162

Name: __________________________________ Phone Number______________________________

Street Address______________________________________________________________________
City/State/Zip_______________________________________________________________________
Relationship to Child___________________ Relationship to Parent(s) _________________________
Name: __________________________________ Phone Number______________________________
Street Address______________________________________________________________________
City/State/Zip_______________________________________________________________________
Relationship to Child___________________ Relationship to Parent(s) _________________________
X_______________________________________ Date______________________________________
CHILD'S NAME_____________________________________________________________________
Child's doctor or clinic name: ___________________________________________________________
Doctor/clinic phone number: ___________________________________________________________
My child has the following special needs: _________________________________________________
__________________________________________________________________________________
The following special accommodation(s) may be required to most effectively meet my child's needs
While at the center: ___________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
My child is currently on medication(s) prescribed for long-term continuous use and/or has the
Following pre-existing illness, allergies, or health
Concerns: ___________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
EMERGENCY MEDICAL AUTHORIZATION
Should (child's name) __________________________________DOB_________________________

Around The Clock Childcare Ltd | 123 Loving Care Lane, Douglasville Ga 30162

Suffer an injury or illness while in the care of Around the Clock Childcare LTD and the facility is unable to
Contact me (us) immediately, it shall be authorized to secure such medical attention and care for
The child as may be necessary. I (We) shall assume responsibility for payment of services.
Parent/Guardian: ____________________________ Signature: _____________________________
Date: _______________________
Facility Administrator_________________________________________________
Date: ________________________
X______________________________________ Date_________________________________

Around The Clock Childcare Ltd | 123 Loving Care Lane, Douglasville Ga 30162