Children's Castle Child Care Inc. - Jacksonville, NC - Enrollment

301 Yaupon Drive -- 910-346-8555

851 Dennis Road -- 910-455-8558

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ENROLLMENT

Enrollment

Enrollment Application

Contact Us

E-Mail

Child's First Name

Child's Last Name

Date of Birth

Center Interested In

Enrollment Date

Age

Sex

Class

Mother's Name

M - Address

M - Home Phone

M - Employer

M - Employer Address

M - Work Phone

M - Cell Phone

M - Email

Father's Name

F - Address

F - Home Phone

F - Employer

F - Employer Address

F - Work Phone

F - Cell Phone

F - Email

Who Does the Child Live With

Emergency Contact #1 (Other Than Parents)

E1 - Address

E1 - Home Phone

E1 - Work Phone

Emergency Contact #2 (Other Than Parents)

E2 - Address

E2 - Home Phone

E2 - Work Phone

Child's Physician

CP - Phone

CP - Address

Pickup Person #1 - Name

PP1 - Relationship to Child

PP1 - Address

PP1 - Home Phone

PP1 - Work Phone

Pickup Person #2 - Name

PP2 - Relationship to Child

PP2 - Address

PP2 - Home Phone

PP2 - Work Phone

Pickup Person #3 - Name

PP3 - Relationship to Child

PP3 - Address

PP3 - Home Phone

PP3 - Work Phone

Pickup Person #4 - Name

PP4 - Relationship to Child

PP4 - Address

PP4 - Home Phone

PP4 - Work Phone

Is there anyone NOT ALLOWED to pickup your child?

NA - Name

NA - Relationship to Child

NA - Phone

NA - Reason

Child's Allergies

Current Prescribed Medication

Child's Special Medical needs and Conditions

Date of Last Tetanus

Pre-School: Child Care Arrangment for Illnesses

Pre-School: Has Your Child Had The Following?

Measles (Big Red)

Measles (3 Days)

Giardia

Fifth's Disease

Hepatitis B

Chicken Pox

Whooping Cough

Other

Pre-School: Any Serious

Illnesses/Hospitalization

Specify if Yes

Pre-School: Any Physical Disabilities

Specify if Yes

Any Medication To Be Given Regularly

Child's Food Allergies

Child's Insect Allergies

Child's Medication Allergies

Child's Other Allergies

Can the Child Reliably Indicate Bathroom Wishes?

Does the child have frequent toilet accidents?

How Does Your Child Reach to Them?

What Time Does Your Child Go To Bed?

What Time Does Your Child Awaken From Bed?

What Is Your Child's Mood On Awakening?

What Is Your Child's Nap Schedule?

Will Your Child Adjust Easily To Child Care?

How Does Your Child Show His/Her Feelings?

What Makes Your Child Angry or Upset?

By Nature, Is Your Child

Friendly

Shy

Withdrawn

Aggressive

Is your child frightened by any of the following?

Animals

Dark

Stories

Loud Noise

I have read and accept the statement to the right

Yes

I certify that the facts contained in this application are true and complete to the best of my knowledge

Thank you for contacting us.
We will get back to you as soon as possible.

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Children’s Castle Child Care with 3 Convenient Locations to Serve You

301 Yaupon Dr.

Jacksonville, NC 28546

Piney Green

910-346-8555

Hours of Operation

5:45 am - 6:00 pm

Monday through Friday

851 Dennis Rd.

Jacksonville, NC 28546

School Age Care

910-455-8558

Hours of Operation

6:00 am - 6:00 pm

Monday through Friday

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