Little Lotus Registration

Little Lotus Playgroup Registration 2022-2023

Learning and Growing Together
Parent 1 Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Email *
example@example.com
Parent 2 Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Email *
example@example.com
Start Date *

Month Day Year
Date
Child's Name *

First Name Last Name
D.O.B *

Month Day Year
Date
Please let us know which days your child/children will attend. Classes are 9am-4pm or 9am-1pm *

Monday 9am-5pm 9am-1pm Tuesday 9am-5pm 9am-1pm Wednesday 9am-5pm 9am-1pm Thursday 9am- 5pm 9am-1pm Friday 9am- 5pm 9am-1pm
Home Phone Number *

Area Code Phone Number
Child's Address *

Street Address

Street Address Line 2

City State / 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................$100.00
Signature *

Clear
My Products *

prev next ( X )
USD registration fee
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

Little Lotus Playgroup Registration 2022-2023