Enrollment Application and Admission Record

Version 2026.1 · Effective August 23, 2026

Child

• Full name: _____________________________________________________
• Preferred name: ________________________________________________
• Date of birth: ____________________
• Requested start date: ____________________

Parent/guardian information

Parent/guardian home address(es): __________________________________

Parent/guardian employer and work address(es): ______________________

Instructions for reaching parent/guardian during care: ______________

__________________________________________________________________

Requested schedule

• Requested days: ☐ Monday ☐ Tuesday ☐ Wednesday ☐ Thursday
• Requested arrival time: __________ Requested pickup time: __________
• Requested schedule or notes: ____________________________________

Enrollment is subject to availability, completed records, licensing requirements, and the signed contract.

Pre-admission interview

• Interview date: ____________________
• Interview participants: _________________________________________
• Child’s routines, needs, and interests discussed: ________________

_______________________________________________________________

• Questions or follow-up items: ___________________________________

_______________________________________________________________

Required accompanying documents

☐ Child medical record

☐ Emergency medical authorization

☐ Authorized pickup form

☐ Immunization certificate or exemption documentation

☐ Applicable health-provider appraisal or care plan

☐ Parent handbook and policy acknowledgment

☐ Signed childcare contract

☐ Private itemized fee schedule

☐ Applicable safe-sleep, medication, or topical-care authorizations

Medical forms and addenda must be returned within 15 days of enrollment unless a different lawful deadline applies.

Parent certification

I certify that the information provided is accurate and agree to notify Teida’s Tots promptly when information changes. I understand that enrollment is not complete until required documents are received and the contract is signed.

• Parent/guardian signature: ______________________________________
• Printed name: _________________________________________________
• Date: ____________________

Provider admission record

• Admission decision: ☐ Accepted ☐ Pending ☐ Declined
• Date: ____________________
• Provider notes: ________________________________________________

_______________________________________________________________

• Provider signature: ____________________________________________