Child Care Enrollment

Fill this out on any device. When you finish, you'll get the official state form (DCF-F-CFS0062) completed with your answers, ready to print and send to PNCC.

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Child Information

Child's name (Last, First, MI) *

Birthdate *First day of attendance

Parent / Guardian A

Name and relationship to child *Home / cell phone *Email (reachable while child is in care)Place of employment & work phone

Home address (street, city, state, zip) *

Does child reside at this location?

yesno

Parent / Guardian B

Optional

Name and relationship to childHome / cell phoneEmail (reachable while child is in care)Place of employment & work phone

Home address (street, city, state, zip)

Does child reside at this location?

yesno

Authorized Persons

People other than parents allowed to pick up or drop off your child. If no one, write "None".

Person A

Name and relationship to childHome / cell phoneEmail (reachable while child is in care)Place of employment & work phone

Person B

Name and relationship to childHome / cell phoneEmail (reachable while child is in care)Place of employment & work phone

Emergency Contact

Who to notify when parents/guardians can't be reached.

Name and relationship to child *Home / cell phone *Email (reachable while child is in care)Place of employment & work phone

This person is authorized to pick up the child.

yesno

Physician or Medical Facility

NameAddress (street, city, state, zip)Telephone

Authorizations

I give my consent for emergency medical care or treatment to be used only if I cannot be reached immediately.

yesno

I have had an opportunity to review the policies of this child care center and a summary of the Wisconsin Rules for Licensing Child Care Centers.

yesno

I give permission for my child to participate in field trips and other activities during operating hours.

yesno

Transported Walking

I have been informed of the number of pets in the center and their degree of contact with the enrolled children.

yesno

Signature

Sign with your finger or mouse.

Printed name *Date signed *