Background
Information:
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Father's Name
Mother's Name
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Child's Address
City
State
Zip Code
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Child's Home Phone # Parent's Work Phone
# Parent's Mobile
Phone #
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Parent's E-mail Address
Parent's Fax #
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Parents' Marital Status Married
Separated Single
Divorced
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Emergency Contact Address
Phone Relationship
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If child/ren will be with relatives or family friends, but not with parents or legal guardians, please explain
the custodial relationship below.
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_________________________________________________________________________________________________
Custodian's Name
Address
Mobile Phone #
_________________________________________________________________________________________________
Custodian's E-mail Address
Custodian's Fax #
If applicant with
child/ren will be staying in a Chicago hotel, please give the following:
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Name of Hotel
Address
Room #, when available
Dates and Times that childcare will be needed:
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Names
& Birthdates of Children:
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Please list any allergies or other medical conditions that
apply to any child.
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Please list any medications that will be given by the parent or custodian
to any child.
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Please list any preferences you have regarding
the child/ren's activities while with our caregiver.
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Please give your reason for needing childcare at this time. Where will
you be?
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Do you have any particular rules that you wish our caregiver to enforce?
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What are some activities, learning materials, or toys that your child particularly
enjoys?
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Please describe your child's eating habits.
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Please describe any child with special needs.
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Please describe any preferences regarding the caregiver we send to you.
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