Little Lotus Registration

Little Lotus Playgroup Registration 2024-2025

Learning and Growing Together
Parent 1 Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Parent 2 Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Start Date*

MonthDayYear
Date
Child's Name*

First NameLast Name
D.O.B*

MonthDayYear
Date
Please let us know which days your child/children will attend. Classes are 9am-5pm or 9am-1pm*

Monday 9am-5pm9am-1pmTuesday 9am-5pm9am-1pmWednesday 9am-5pm9am-1pmThursday 9am- 5pm9am-1pmFriday 9am- 5pm9am-1pm
Home Phone Number*

Area CodePhone Number
Child's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
- As your childcare provider, I agree to provide your child with careful attention, affection, supervision and interesting things to do. I agree to help you enjoy your early parenting experience and communicate regularly with you about your child’s development in all areas.
- Provide nutritious snacks at appropriate times.
- Give you adequate notice, except in an emergency, if I request removal of your child from our care.
- Coordinate with you in planning for the needs of your child.
- As a state mandated reporter, I am required to report to authorities any suspected abuse/maltreatment or wrong doing of your child.
Please list any siblings in the family, and their ages: _______________________________________________

Does your child have any special interests (trains, trucks, dinosaurs, Elmo, etc.?) Please write a short note about
your child, this way we can get an idea of who they are, what they like/dislike, and most importantly what makes them happy!
By signing this form, you agree to the policies and practices of Little Lotus Playgroup. You also confirm that you have read the Terms and Conditions in the Little Lotus Handbook. Thank you!

Registration fee................$150.00
Signature*

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Little Lotus Playgroup Registration 2024-2025