Infant/Toddler Application

Child's Name(Required)
Primary Caregiver(Required)
Home Address(Required)

Secondary Caregiver

Secondary Caregiver Name

Emergency Contacts

List all other adults (must be over 18) authorized to take the child from the center.
Emergency Contact Name(Required)
Emergency Contact 2 Name
Emergency Contact 3 Name
Emergency Contact 4 Name

Medical Information:

Physician's Address(Required)
do hereby give my consent to the director of Lincoln Childcare Center or a designated representative, for said child to receive medical or surgical aid as may be deemed necessary and expedient by a duly licensed or recognized physician or surgeon in case of an emergency when the parent cannot be reached. Consent is also given to the Director or appointed representative to transport said child for emergency medical treatment if the parents cannot be reached.
I authorize the Department of Health to disclose immunization records to Lincoln Childcare Center, Inc. I understand that this authorization will expire upon the discharge of the child from the facility.

Hours of Care

In order to provide the best care for your child we need to know what hours of care you are needing. This information is used for staffing patterns so we provide the best care for your child and provide consistency in caregivers. Please follow the schedule you select as close as possible and if you need to change let us know. Center Hours: Monday-Friday 6am-6pm
will attend Lincoln Childcare Center between the following hours.
Your child may be subject to interviews by DHS licensing staff, child maltreatment investigators, and/or law enforcement officials for the purpose of determining licensing compliance or for investigative purposes. Child interviews do not require parental notice or consent. Children may be interviewed individually or in a group. Licensing compliance forms are available for review on line at the Division of child care and early childhood education website.
For and in consideration of the permission of Lincoln Childcare Center,Inc (LCC) to enter upon its premises, plant, and for the purpose of providing childcare for my children. I do hereby release and forever discharge LCC and any and all of its divisions, officers, and employees from any and all manner of claims, causes of action, or liability, which I or my child(ren) now have or may ever have at any time in the future, against LCC its’ divisions officers or employee, arising out of or pertaining to any injury, loss, damage, or harm of any kind which has, will or may result or happen to me or my child(ren) while I or my child(ren) am on or about the property, plant, or premises of said corporation. I do hereby assume all risk of any damage, injury, or loss which may occur to me or my child(ren) in going to, from, or upon the property, plant or premises of LCC, or any of its divisions. For the same consideration previously stated, I do hereby agree to indemnify, defend, protect, and hold harmless LCC, and its divisions, claims, causes of action, or liability, arising out of any accident, injury or damage to me or my child(ren) occurring while I or my child(ren) am on or about the property, plant or premises of LCC or any of its divisions. This release shall remain in full force and effect until or unless revoked in writing by both myself and an officer of LCC and in any event it shall remain in full force and effect so long as I or my child(ren) shall or may be upon the premises, plant, or property of LCC or any of its divisions for any purpose whatsoever, at any time after the date hereof. I hereto set my hand and have agreed to the terms of this instrument after carefully read it in full.

Getting to Know You

We believe families play an important role in the learning process for their child. We want to get to know your child and your family so we can better educate your child.
This field is for validation purposes and should be left unchanged.