Lollipop Stop Child Development Center Child’s Application for Enrollment
To be completed, signed, and placed on file in the facility and updated as changes occur and at
least annually.
Date Application Completed:_______________ Date of Enrollment:________________
Child’s Information:
Date of Birth
Child’s Legal Name
Last
First
Middle
Child’s Physical Address
Street
City
State
Zip Code
Typical Hours of Care:
M:
T:
W:
Th:
F:
Father’s/Guardian’s
Information:
Date of Birth:
Child Lives With:
Yes No
Social: Last 4
Father’s/Guardian’s Legal
Name
Last
First
Middle
Mailing Address (If Different)
Street
City
State
Zip Code
Contact:
Work
Extension
Place of Employment
Cell
Home
Email
Mother’s/Guardian’s
Information:
Date of Birth:
Child Lives With:
Yes No
Social: Last 4
Mother’s/Guardian’s Legal
Name
Last
First
Middle
Mailing Address (If Different)
Street
City
State
Zip Code
Contact:
Work
Extension
Place of Employment
Cell
Home
Email
Contacts:
Child will only be released to the parents/guardians listed above. The child can also be released to the following
individuals, as authorized by the person that signs this application. In event of an emergency, if the
parents/guardians cannot be reaches, the facility has permission to contact the following individuals.
Name
Address
Phone Number
Name
Address
Phone Number
Name
Address
Phone Number
Name
Address
Phone Number
Name
Address
Phone Number
Name
Address
Phone Number
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