Enrollment Application

Enrollment Application
Thank you for your interest in applying. Please complete and submit this enrollment application at your earliest convenience. Please note there is a non-refundable registration fee of $25 registration due immediately upon the submission of this form.
Child’s Demographics
Child's Full Name: *
Nickname:
Date of Birth: *

Month Day Year
Date
Age: *
Example: 3yrs. 5 mons.
Child's Preferred Language: *
Address *

Address

Street Address Line 2

City/State

Zip
Allergies/Special Diets *
Example: peanuts, treenuts, vegan, etc.

Parent Information

Mother's Information
Parent/Guardian #1: *
Home Address (if different):
Home Number *

Area Code Phone Number
Cell Number *

Area Code Phone Number
Email *
example@example.com
Preferred Language *
Please provide us your work location, number and best ways to reach you when you are at work.
Workplace: *
Work Number *

Area Code Phone Number
How can we contact at work? *
Examples: call, emaill, extension number, etc.

Parent Information

Father's Information
Parent/Guardian #2:
Home Address (if different)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Number

Area Code Phone Number
Cell Number

Area Code Phone Number
Email Address:
example@example.com
Preferred Language
Please provide us your work location, number and best ways to reach you when you are at work.
Workplace:
Work Number

Area Code Phone Number
How can we contact you at work?
Examples: call, emaill, extension number, etc.

Emergency Contacts

In the event of an emergency when you can not be reached, the learning center may contact the following individuals whom are also authorize to take your child from the child care premises in cases of emergency. Contacts listed must be able to provide transportation.
(1) Name: *
Relationship *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Number *

Area Code Phone Number
Cell Number *

Area Code Phone Number
(2) Name: *
Relationship: *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Number *

Area Code Phone Number
Cell Number *

Area Code Phone Number

Transportation Plan/ Authorized Pick-up

Please let us know how your child will be arriving and departing the center.
My child will arrive to the program by: *

Parent Drop-off Public Bus Private Transportation Provided by Parent
My child will depart the program by: *

Parent Pick-up Public Bus Private Transporation Provided by Parent
In the space below, please note any important information regarding transportation of your child to and from the program (i.e. indicate who will be supervising children during transport or prior to their arrival at home/program who will be placing/receiving the child to and from the van/bus, etc.)
Authorized Pick-Up

Please provide a list individuals who are authorized to take your child from the center's premises, in the event that you can not pick up your child.
(1) Name *
Address *
Home Number *

Area Code Phone Number
Cell Number *

Area Code Phone Number
(2) Name *
Address *
Home Number *

Area Code Phone Number
Cell Number *

Area Code Phone Number

Anticipated Days & Time of Attendance

Hours of Operation 7:00am-5:00pm
What days of the week will your child be attending? *

Monday Tuesday Wednesday Thursday Friday
Arrival Time *

: Hour Minutes AM/PM Option
Departure Time *

: Hour Minutes AM/PM Option
If your arrival and departure times are different each day, please list what those days and times are.
Additional Legal Documents

Copies of any custody agreements, court orders, restraining orders (if applicable)
If any, please provide a list of documents that we will be recieving from you.
Any previous experience in child care? If yes, how was that experience?
Is there anything else we should know about your child? Are there any developmental or physical concerns that we need to know? If yes, what are they?

Parent Information