Child Care Application Form

Child Care Application Form
If you want your child to be care by someone else, please fill out this form.
Child Info
To whom your child care is given?
Your relationship with them -
- Very near relative
- Close Friends
- Neighbour
- Other
Is your child care by them before?
- Yes
- No
Do your child suffer from any health problems?
- Yes
- No
Any Regular medications?
- Yes
- No
If your child wish to go to someone else in between the care period, refer the second person.
Consent to medical care and treatment of minor children.

I give permission that my child,
may be given first aid/emergency treatment by a the child care licensee and/or qualified staff at :
- When I cannot be contacted, I authorize and consent to medical, surgical and hospital care, treatment and procedures to be performed for my child by a licensed physician, health care provider, hospital or aid car attendant when deemed necessary or advisable by the physician or aid car attendant to safeguard my child's health. I waive my right of informed consent to such treatment. I also give my permission for my child to be transported by ambulance or aid car to an emergency center for treatment. I certify under penalty of perjury under the laws of the State of Washington that this information is true and correct.

Child Info