Daycare Enrollment Form

Childcare enrollment and intake form for US daycare and childcare centers

This daycare enrollment form gives a US childcare center one printable, fillable record to enroll a new child — child, parent/guardian, emergency and authorized-pickup, immunization, and health details in the shape US state childcare licensing agencies commonly expect on file, so a family completes one document instead of a scattered stack of intake paperwork.

State childcare licensing requirements vary — this template reflects the baseline that recurs across state agencies. Confirm your own state’s licensing agency for its specific deadlines and required categories before relying on this form for a licensing inspection.

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How to use this template

• Complete one form per child before their first day of care, and keep it on file for the length of their enrollment, as most state licensing agencies require.
• The form must be completed by a parent or legal guardian — the person authorized to give the consents in the Policies & Signature section.
• Answer every Yes/No item; leave no consent line blank, since a blank line cannot be treated as agreement.
• Write “N/A” where a field genuinely does not apply (for example, a second guardian in a single-guardian household) rather than leaving it empty.
• List at least two adults, besides the guardians, who may be contacted or may collect the child — staff will check photo ID at pickup for anyone not already known to them.
• Attach current immunization records (or documentation of an exemption recognized by your state) and any required health statement before or shortly after the child’s first day, per your state’s deadline.
• Tell the center immediately whenever any detail changes — especially contacts, allergies, medications, or who may collect the child.

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Section 1: Enrollment & program details

Center / organization name: [ORGANIZATION NAME] Classroom / group: [CLASSROOM OR GROUP] Requested start date: [REQUESTED START DATE] Attendance schedule (days and hours): [ATTENDANCE DAYS AND HOURS] Participates in the Child and Adult Care Food Program (CACFP): ☐ Yes ☐ No ☐ Not sure

Filled in by the center at intake. If the center participates in CACFP, a separate Income Eligibility Application may be offered — completing it is always optional and never a condition of enrollment.

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Section 2: Child information

Full legal name: [CHILD FULL LEGAL NAME] Preferred name (if different): [CHILD PREFERRED NAME] Date of birth: [CHILD DATE OF BIRTH] Home address: [CHILD HOME ADDRESS] Language(s) spoken at home: [LANGUAGES SPOKEN AT HOME]

Enter the child’s identity exactly as it appears on their birth certificate or other official documents.

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Section 3: Parent / guardian details

Guardian 1

Full name: [GUARDIAN 1 FULL NAME] Relationship to child: [GUARDIAN 1 RELATIONSHIP] Holds legal parental authority: ☐ Yes ☐ No Address: [GUARDIAN 1 ADDRESS] Mobile phone: [GUARDIAN 1 MOBILE] Email: [GUARDIAN 1 EMAIL]

Guardian 2 (if applicable)

Full name: [GUARDIAN 2 FULL NAME] Relationship to child: [GUARDIAN 2 RELATIONSHIP] Holds legal parental authority: ☐ Yes ☐ No Address: [GUARDIAN 2 ADDRESS] Mobile phone: [GUARDIAN 2 MOBILE] Email: [GUARDIAN 2 EMAIL]

A guardian must hold legal parental authority to give the consents in the Policies & Signature section. Write “N/A” for Guardian 2 in a single-guardian household.

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Section 4: Emergency & authorized-pickup contacts

People, besides the guardians above, who may be called if a guardian cannot be reached and/or may collect the child. Do not repeat a guardian already listed above. List at least two.

Contact 1

Full name: [CONTACT 1 NAME] Relationship to child: [CONTACT 1 RELATIONSHIP] Phone: [CONTACT 1 PHONE] Authorized to pick up the child: ☐ Yes ☐ No

Contact 2

Full name: [CONTACT 2 NAME] Relationship to child: [CONTACT 2 RELATIONSHIP] Phone: [CONTACT 2 PHONE] Authorized to pick up the child: ☐ Yes ☐ No

Custody or legal restrictions (if applicable)

Details of any court order or legal restriction on contact with, or pickup of, the child: [CUSTODY OR LEGAL RESTRICTION DETAILS — LEAVE BLANK IF NONE]

Leave blank if no restriction applies; if one does, attach a copy of the court order for the center’s file.

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Section 5: Immunization & health information

Immunization status: ☐ Current immunization record on file ☐ Exemption on file ☐ Pending — to be provided by [DATE IMMUNIZATION RECORD DUE] Exemption type, if applicable (medical / religious / other basis your state recognizes): [EXEMPTION TYPE] Known allergies (food, medication, environmental): [KNOWN ALLERGIES] Chronic conditions or additional needs: [CHRONIC CONDITIONS OR ADDITIONAL NEEDS] Current medications (name, dose, schedule): [CURRENT MEDICATIONS] Primary physician — name and phone: [PRIMARY PHYSICIAN NAME AND PHONE] Preferred hospital or emergency medical facility: [PREFERRED HOSPITAL OR EMERGENCY FACILITY] I authorize center staff to administer the medication(s) listed above, as directed: ☐ I authorize ☐ I do not authorize I authorize the center to seek emergency medical treatment for my child if a guardian cannot be reached immediately: ☐ I authorize ☐ I do not authorize

Many states require a health or physician statement within a set number of days after enrollment — confirm your own state’s deadline and write it into the immunization line above. Write “None” rather than leaving a medical field blank, so staff know it was seen and answered, not skipped.

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Section 6: Dietary notes

Dietary restrictions or feeding notes (allergies already listed above need not be repeated): [DIETARY RESTRICTIONS OR FEEDING NOTES]

Separate from any CACFP Income Eligibility Application noted in Section 1 — this line is for the center’s meal-planning use only.

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Section 7: Policies & signature

I confirm I have received and reviewed the center’s parent handbook and policies, including its withdrawal / termination policy: ☐ Yes Photo/video use in the center’s day-to-day records (not public posting): ☐ I authorize ☐ I do not authorize Guardian signature: [GUARDIAN SIGNATURE] Date: [SIGNATURE DATE]

The signing guardian must be the person named as holding legal parental authority in Section 3. For public posting, social media, or website use of photos or video, use a dedicated photo/video consent form instead of the line above.

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Section 8: For office use only

Date received: [DATE RECEIVED] Staff initials: [STAFF INITIALS] Licensing file checklist confirmed (immunization, health statement, emergency contacts on file): ☐ Yes

Completed by the center at intake — not filled in by the family.