Enrollment Form

Child Information
MonthDayYear
Today's Date
Child's name*
Gender*
Date of birth*

MonthDayYear
Home Street Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Finding directions
ZIP
County
Parent or guardian name, adult whom child lives with*
Phone*

Area CodePhone Number
Alternate phone

Area CodePhone Number
Place of employment
Business phone

Area CodePhone Number
Email*
example@example.com
Is there another parent or guardian name, adult whom child lives with*

YesNo
Parent or guardian name, adult whom child lives with
Phone

Area CodePhone Number
Alternate phone

Area CodePhone Number
Place of employment
Business phone

Area CodePhone Number
Email
example@example.com
Emergency Contact

List individuals to notify, in case of emergency, when the parent or guardian cannot be reached. List in order of preference:
Name*
Phone Number*

Area CodePhone Number
Name*
Phone Number*

Area CodePhone Number
Name
Phone Number

Area CodePhone Number
Name
Phone Number

Area CodePhone Number
Name
Phone Number

Area CodePhone Number
Immunization Record

Parent/guardian must provide a copy of the current updated immunization record to the child care program. Refer to Appendix II, Immunizations, in Requirements for Child Care Programs for immunization and exemption procedures.
Upload a copy of the child's immunization record. An immunization record or exemption is obtained prior to the first day of attendance and is to be updated when the child receives additional vaccines.

Browse Files

Cancelof
Health Record
Child's physician or clinic
Phone

Area CodePhone Number
Address

Street address

Street Address Line 2

CityState / Province

ZIP
*

I understand that a signed parent/guardian permission is obtained prior to administration of any medication to any child.
Does your child have any specific needs involving routine care, behavior modification, communication, eating, or sleeping activities? When yes, describe:
Does your child have any known allergies?*

YesNo
When yes, list:
Does the known allergy require special precautions, actions, or medications?*

YesNo
When yes, describe:
Describe any special precautions for diet, medication, or activity, when applicable:
Are there any other special considerations that would assist this program in providing care to your child? When yes, describe:
Will your child receive any specialized services from professionals outside of this program's personnel?*

YesNo
When yes, I understand that a signed and dated parent permission is required.
I give permission for program personnel to consult with specialized personnel regarding the needs of my child?*

YesNo
Transportation
Type a question*

I do not give permission to transport my childI give permission for my child to be transported by this program under the following circumstances:
Select all that apply:

When an emergency occurs and I cannot be reachedField Trips
Pick Up Permission

Individuals who have permission to pick up my child:
Name*
Phone Number*

Area CodePhone Number
Name*
Phone Number*

Area CodePhone Number
Name
Phone Number

Area CodePhone Number
Signature
I understand this form is supplied by the Oklahoma Human Services (OKDHS) for the convenience of the child care program and me to assist with care of my child. Supplying this form in no way imposes any responsibility or obligation upon OKDHS. Program policies are provided to parents upon enrollment and when revisions are made. Selecting Quality Child Care - A Parent Guide, DHS publication 87-91, Licensing Requirements for Child Care Programs, DHS publication 14-05, and the program compliance file are all made accessible to parents in a prominent location.*

Clear
Date

MonthDayYear
Date
Childcare Program Use
Date child entered program

MonthDayYear
Date child withdrawn

MonthDayYear
Financial Aid

We strive to make the enrollment process as convenient as possible for you. That's why we gladly accept multiple forms of payment
Form of Payment*

DHS SubsidyPrivate PayCreek NationCherokee NationOttawa TribeModoc TribeAmeri CorpsEmployment ReimbursementOther

Enrollment Fee*

1 Child$75.00

Family (More than 1 child)$125.00

Enter coupon

Total $0.00

Type a question*

I understand that the registration fee is required upon enrollment.I understand that this fee is non-refundable and will hold a space for my child(ren), pending availability.

Payment Methods

Debit or Credit Card

First Name

Last Name

Credit Card Number

Security Code

Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

Should be Empty:

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