Gingerbread House Daycare Enrollment Form
In order to complete this application, you will need your child's immunization record, birth certificate, and the ability to print out and scan in (or take photos of) forms that require a signature. If you do not have those items, you will need to collect the required information before filling out the application.
Required forms can be found at https://www.gingerbreadcenter.org/faq. Please have the following forms ready: 1) Preventative Creams and Ointments 2) Emergency Medical Authorization 3) Parent Handbook Receipt & Acknowledgement 4) Permissions for Video Tape, Photo, Field Trips, and Screenings 5) Income Eligibility Form. If your child has allergies or requires a special diet, please have that form filled out by a physician prior to completing this application. All children are also required to have a general physical completed by a doctor within 30 days of enrollment.
Child's Full Name
*
Date of birth
*
Gender
*
Male
Female
Child's Race/Ethnicity
*
American Indian
Asian/Pacific Island
Black
Hispanic
Anglo/White
How did you hear about our program
*
Newspaper
Telephone Book
Friend
Relative
Other
Address:
*
Mailing address (if different):
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Family Information
Mother's Name
*
Mother's Cell Phone
*
Mother's Email Address
*
Mother's Employer
*
Mother's Work Phone
*
Average Monthly Income for Mother
*
Number in Mother's Household
*
Family Information for mother (or custodial guardian)
Child lives with:
*
Has your child attended any other Head Start or preschool programs previously? If so please list
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Family Information
Father's Name
*
Father's Cell Phone
*
Father's Email Address
*
Father's Employer
*
Father's Work Phone
Average Monthly Income for Father
*
Number in Father's Household
*
Family Information for Father (or custodial guardian)
If families enroll a child in preschool at the same time, in two different school districts, then those families may be responsible for paying tuition to one of those districts.
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Emergency Contact Info
Emergency Contact Name
*
Emergency Contact Place of Work
*
Emergency Contact Address
*
Child's Doctor
*
Doctor's Phone Number
*
Doctor's Address
*
Child's Dentist
*
Dentist's Phone Number
*
Dentist's Address
*
People with Permission to Pick Up
*
Pick up Name, Relationship, & Phone Number
Pick up Name, Relationship, & Phone Number
Pick up Name, Relationship, & Phone Number
Pick up Name, Relationship, & Phone Number
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We are asking the following questions to help us better meet your child’s needs. Please be assured that his information will not be shared with anyone besides your child’s teacher.
Child's Birth Weight
Was your child full-term?
*
Yes
No
If no, how many weeks premature?
Were there any medical issues at delivery or shortly thereafter? Please explain
*
Has your child experienced any other medical issues (other than typical colds)? If yes, please describe:
*
Please list and explain any allergies your child has.
Please describe any history of learning problems in family.
Do you have any concerns about your child’s development? If so please describe
*
Has your family experienced any recent changes such as: moving, births, deaths, divorce, unemployment. If so please describe:
*
Is your family affected by any major stresses such as: military deployment, immigration, loss of a parent or disability? If so, please describe:
*
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What is the mother’s level of education:
*
Was her overall school experience: positive, negative or neutral?
*
What is the father’s level of education:
*
Was his overall school experience: positive, negative or neutral?
*
Names and ages of family members in the home:
*
Does your family have health insurance or other funding for medical care? What type?
*
Are you an ASU Student:
*
Yes
No
Are You ASU Faculty or Staff:
*
Yes
No
If yes, what Department at ASU?
Is your Child in:
*
Diapers
Transitioning
Fully Potty Trained
If in Diapers- Diaper Brand:
Diaper Size:
How many hours of weekly care are you requesting (all requests are subject to availability)
*
More than 23 Hours a week (Considered Full-time care, care available from 7:30-5:30)
Less than 23 hours a week (Considered Part-time care, choose this if you have a preschool requiring wrap-around care)
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Parent Participation Form
Family participation is vital to any education program. Our goal is to have each family participate in at least one activity each month. Below is a list of ways you can participate in your child's education. Please check any way you can help.
Ways to participate
I can visit the classroom to tell about my occupation, help with an art activity, share my culture, read a story, or just enjoy the day with my child.
I can volunteer for fieldtrips
I will participate in Parent Teacher Conferences
I can attend school education/social events. (When possible, we have family nights once a month, and we have family events during the day.)
I can participate in home visits.
I am interested in lunches and/or breakfasts that may be held at the school for families.
My child has other family members who would enjoy attending events or volunteering (for example Grandma, Grandpa, Aunt, Uncle, or older brothers or sisters, etc.)
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Please Upload the Following Requirements
Please upload your Child's Immunization Record
*
Immunization Record
Please upload your child's Birth Certificate
*
Birth Certificate
The following forms are required to submit an application for enrollment. Simply visit https://www.gingerbreadcenter.org/faq and print out the required forms. Fill them out, sign them, and upload them to this application. You can take a photo or scan in the forms.
Please upload a physical exam form filled out by a health provider (optional at this time, but due within 30 days after your child begins)
Physical exam certificate
Please Upload the Preventative Creams and Ointments Permission Form
*
Preventative Creams and Ointments
Please Upload the Emergency Medical Authorization Form
*
Emergency Medical Authorization
Please upload the Parent Handbook Receipt and Acknowledgement Form
*
Parent Handbook Receipt and Acknowledgement
Please Upload the Permissions Form (Video Tape, Photo, Field Trip, Screenings)
*
Permissions for Video Tape, Photo, Field Trip & Screenings
Please upload the Income Eligibility for Child Care form (provides reimbursement for meals and snacks)
*
Income Eligibility
If your child has allergies, please upload a completed Allergy Form signed by a physician (optional)
Allergy Form
If your child requires a special diet, please upload the Special Diet Form (optional)
Special Diet
By submitting this application, I understand that I have given full and accurate information on this application.
I understand
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