MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
SECTION FOR CHILD CARE REGULATION
CHILD ENROLLMENT
CHILD’S NAME
SEX
BIRTH DATE
ADDRESS (STREET, CITY, STATE, ZIP CODE)
HOME TELEPHONE NUMBER
( )
SCHOOL CHILD ATTENDS
NAME
TELEPHONE NUMBER
( )
OPTIONAL ADDRESS (STREET, CITY, STATE, ZIP CODE)
IDENTIFYING INFORMATION
MOTHER’S OR GUARDIAN NAME
HOME TELEPHONE NUMBER
( )
ADDRESS □ CHECK HERE IF SAME AS CHILD. (OR LIST STREET, CITY, STATE, ZIP CODE.)
CELL PHONE NUMBER (OPTIONAL)
( )
EMPLOYED BY (OR SCHOOL ATTENDED)
HOURS OF EMPLOYMENT
FROM TO
ADDRESS (STREET, CITY, STATE, ZIP CODE..
BUSINESS TELEPHONE NUMBER
( )
FATHER’S OR GUARDIAN’S NAME
HOME TELEPHONE NUMBER
( )
ADDRESS □ CHECK HERE IF SAME AS CHILD. (OR LIST STREET, CITY, STATE, ZIP CODE.)
CELL PHONE NUMBER (OPTIONAL)
( )
EMPLOYED BY (OR SCHOOL ATTENDED)
HOURS OF EMPLOYMENT
FROM TO
ADDRESS (STREET, CITY, STATE, ZIP CODE)
BUSINESS TELEPHONE NUMBER
( )
EMERGENCY CONTACT(S) (ONE REQUIRED)
NAME
TELEPHONE NUMBER
( )
ADDRESS (STREET, CITY, STATE, ZIP CODE)
RELATIONSHIP
NAME
TELEPHONE NUMBER
( )
OPTIONAL ADDRESS (STREET, CITY, STATE, ZIP CODE)
RELATIONSHIP
PERSONS AUTHORIZED TO TAKE CHILD FROM CHILD CARE FACILITY (ONE REQUIRED)
NAME
NAME
COMMENTS ON CHILD’S DEVELOPMENT
(NOTE ALLERGIES, HABITS, SPECIAL LANGUAGE, ETC.)
TO BE COMPLETED BY CHILD CARE FACILITY (FORM TO BE RETAINED FOR ONE YEAR AFTER DISCHARGE)
FACILITY NAME
ADMISSION DATE
ENROLLED FOR (DAYS OF THE WEEK)
FULL TIME/PART TIME
HOURS PER DAY
FROM TO
DISCHARGE DATE
MO 580-1932 (2-07)
PLEASE COMPLETE BACK
BCC-7
CHILD’S NAME
AUTHORIZATION FOR EMERGENCY MEDICAL CARE
I understand that I will be notified at on