MCDC Application 2022

Muckleshoot Indian Tribe Child Development Center Check list
Please upload a photo of your tribal ID
Please upload a photo of your child's birth certificate
Please upload a photo of your child's immunization
Copy of any legal documents (if applicable) parenting plan, no contact/restraining orders, guardianship court order, ICW relative placement letter
Please include any documents you would like to attach for our records

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Employment Verification Sponsor and Co-sponsor: You will receive an automated email with an employment verification document attached once this application is submitted. Please forward the employment verification to your supervisor to complete.
All items on the checklist must be received in order for the application to be considered complete.

You will receive an automated email as soon as your application is complete with all documents received.
Muckleshoot Indian Tribe Child Development Center Application for Enrollment
Sponsors Name*

First NameMiddle InitialSponsor’s Last Name
Address*

Street Address

Street Address Line 2

CityState / Province

Zip Code
Home Telephone
Work Telephone
Cellular Phone *
Email Address*
example@example.com
Co-Sponsor's Name

First NameMiddle Initial Last Name
Address

Street Address

Street Address Line 2

CityState / Province

Zip Code
Home Telephone
Work Telephone
Cellular Phone
Email Address
example@example.com
Child's Name (First, Middle ,Last)
Child's DOB

MonthDayYear
Date
Child's Name (First, Middle, Last)
Child's DOB

MonthDayYear
Date
Child's Name (First, Middle, Last)
Child's DOB

MonthDayYear
Date
Child's Name (First, Middle, Last)
Child's DOB

MonthDayYear
Date
Child's Name (First, Middle, Last)
Child's DOB

MonthDayYear
Date
Healthcare Provider (parent/guardian's preferred medical facility for treatment)
Please list your preferred medical facility for treatment*
Address
Date of last well child exam

MonthDayYear
Date
Please list information for additional child(ren)
Date of last dental exam

MonthDayYear
Date
Please list information for additional child(ren)
PERMISSION TO PICK UP YOUR CHILD & IN CASE OF EMERGENCY
(I give my permission for any of the following individuals to be contacted and my child may be released to any of them)
Parent Signature*

Clear
Date

MonthDayYear
Date
Name (First and Last Name)*
Cellular phone number*
Alternate phone number
Name (First and Last Name)
Cellular phone number
Alternate phone number
Name (First and Last Name)
Cellular phone number
Alternate phone number
Who does not have permission to pick up your child? (if court ordered, please provide a copy of the order) Release cannot be denied to biological parents without a court order
Name (First and Last Name)
Relationship to child
REASON
Name (First and Last Name)
Relationship to child
REASON
CONSENT TO MEDICAL CARE AND TREATMENT OF MINOR CHILDREN
I hereby give permission for my child (ren), (please list children names)
If I cannot be contacted; I authorize and give my consent to medical, surgical, or 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 agree and understand that it is my responsibility to keep the Muckleshoot Child Development Center enrollment office; updated on all employment, work phone, and address so they may readily contact me in the event of an accident or emergency.
Signature*

Clear
Date*

MonthDayYear
Date
Employment Verification Section - An email will be automatically sent to the email provided on this application. Please complete the below information, and send the employment verification form you receive to your employer.
Employee Name
Employment
Phone Number
Work Address
Employees Supervisor & Email Address
I hereby authorize the release of my employment scheduled to be verified as needed throughout the year; by the Muckleshoot Child Development Center, for child care information only.
Signature*

Clear
Permission to Release/Request Information
Please list children's names and date of birth below
As a parent/guardian of the child named above, I hereby grant

Muckleshoot Indian Tribe Head Start ProgramMuckleshoot Indian Tribe CCDF ProgramMuckleshoot Indian Tribe Birth to Three Program/Support ServicesMuckleshoot Indian Tribe Child Development Center
To request information relevant to my child/family from

Muckleshoot Indian Tribe Health and Wellness Center: 17500 SE 392 ST. Auburn WA 98092 P:253-939-6648Muckleshoot Indian Tribe Enrollment DepartmentMuckleshoot Casino Human ResourcesMuckleshoot Bingo Hall Human ResourcesMuckleshoot Indian Tribe Finance DepartmentMary Bridge Pediatrics: 202 N Division St #300, Auburn WA 98002 P: 253-876-8088Auburn Health Point: 126 Auburn Ave, Auburn WA 98002 P: 253-735-5066Pediatrics Northwest: 505 S 336th St, Suite 210, Federal Way, 98003 P: 253-927-3243Other (please specify)
Including any or all of the following (as checked below)

Child health information (Well-child Exam, Dental Exam, Immunizations, Lead and Hemoglobin/Hematocrit test results)Family eligibility information, including current family status or employment/income verificationChild’s birth CertificateChild’s Tribal StatusChild developmental/educational information (assessments, progress reports)Information regarding child’s special needs (observations, individual education plan) if applicableFamily Services information (needs assessment, service plan)Other (please specify)
I understand that the confidentiality of any information identifying my child and/or myself will be maintained in accordance with the law and both federal and state regulations. Such information will only be used with my consent for the benefit of my child or me.

By signing below, I also acknowledge that: I may review the indicated information at any time. This authorization is voluntary, and I may refuse to sign it. My refusal to sign will not affect my eligibility for services or enrollment. This authorization will expire one (1) year from the date below, but I may also choose to revoke it at any time.
Parent/Guardian Name
Address
Signature*

Clear
Date

MonthDayYear
Date
Should be Empty:

PERMISSION TO PICK UP YOUR CHILD & IN CASE OF EMERGENCY

CONSENT TO MEDICAL CARE AND TREATMENT OF MINOR CHILDREN

Permission to Release/Request Information