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CDC Application Packet

Step 1 of 6

16%
  • Parents:

    Please fill out this packet completely. At the bottom of this form, attach the following digital paperwork:
    1. Copy of Parent’s Social Security Card
    2. Copy of Child’s SS Card & Birth Certificate
    3. Copy of Child’s Current Immunization Records
    4. Copy of Parent ID
  • o Tour of the center
    o Introduction of teachers
    o Transition period (parent/child/teacher interaction)
    o Admission Requirements:
    - Enrollment Packet
    - Up to date Shot Records
    - Parental Permission and Authorization Form
    - Copy of Parent’s Soc. Sec. Card and Child’s Birth Certificate
    - CCAP Signature Page
    o Hours of Operation/Daily Routine
    o The center does not open until 7:30 a.m.; please do not bring your child to the center early.
    o Child must walk in and out with an adult.
    o Parent Handbook
    o Signing In/Out procedure
    o Third Party Release (authorized persons to pick-up your child)
    o Medical History (allergies, health problems, development)
    o Concerns/Complaint Procedure
    o Diaper bag/Change of clothes
    o Proper clothing for weather
    o Bring child by 8:30 a.m. or notify director if you will be late or leave early.
    o Violent behavior not allowed (guns, weapons, etc.)
    o Do not bring your child’s personal toys, candy, or food.
    o Health policy
    o Immunizations
    o Mandatory health check each morning upon arrival at the center. Your child’s teacher
    will complete the health check and you must stay until completed in case any questions
    arise.
    o Hand washing – parents’ responsibility upon arrival in the classroom each morning.
  • Max. file size: 128 MB.
  • Max. file size: 128 MB.
  • Max. file size: 128 MB.
  • Max. file size: 128 MB.
  • Master Card

  • MM slash DD slash YYYY
  • Mother's Information

  • Father's Information

  • Allergy Information

  • Authorized Release

    My child has permission to be released to the following individuals, child care facilities, or transportation services, in addition to emergency contact persons listed above.
  • Master Card Page 2

  • Language

  • Please tell us which language, if applicable.
  • Physical Background

  • Relationships and Interests

  • Infant/Toddler Information

    Bottle Permission/Feeding Schedule
  • Please understand that the Providence House Child Development Center’s practice is to feed on demand. That is, when an infant is crying to be fed at times other than those listed above, the baby is fed. When an infant refuses a bottle or feeding of solid foods, the baby is not force fed. We will make every effort to follow a parent’s directions on feeding.
  • Parental Permission and Authorization

  • This signature agrees to all of the above.
    We may be contacted by news media concerning issues related to child care and homelessness. We need your permission to allow photographs of your children to be used on television, newspapers, and other publications. Usually children are not identified by name. Let us know your preference. Please select the statement that applies to you and your child, and sign this release form.
  • SPECIAL DIET STATEMENT

    The child named below is a participant in the U.S. Department of Agriculture Child and Adult Care Food Program (CACFP). His/her child care provider is required to provide meals according to the minimum requirements for the CACFP.
    NOTE: Infants do not require a Special Diet Statement for soybean based formula
  • Brief explanation.

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Providence House has worked for more than 30-years helping homeless families with children shed the bonds of extreme poverty and homelessness. Our holistic program initiates systemic change that transforms families and ultimately communities!

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