Application Form

Parent Name*

First NameLast Name
Parent Mobile Number*
Please enter a valid phone number.
Parent Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How Many Children Are You Applying for Enrollment?*

1 Child2 Children3 Children
Child's Name*
Child's Birthdate*

MonthDayYear
Date
Child's Current Grade in School (if summer, choose grade just completed)*

Not Yet in SchoolKindergartenGrade 1Grade 2Grade 3Grade 4Grade 5
Child 2 Name*
Child 2 Birthdate*

MonthDayYear
Date
Child 2 Current Grade in School (if summer, choose grade just completed)*

Not Yet in SchoolKindergartenGrade 1Grade 2Grade 3Grade 4Grade 5
Child 3 Name*
Child 3 Birthdate*

MonthDayYear
Date
Child 3 Current Grade in School (if summer, choose grade just completed)*

Not Yet in SchoolKindergartenGrade 1Grade 2Grade 3Grade 4Grade 5
What Days Do You Need Childcare?

MondayTuesdayWednesdayThursdayFridayOther
Explain
What Time Will You Be Dropping Off Child/Children?*
What Time Will You Be Picking Up Child/Children?*
Will you be applying for financial assistance with CCIS and/or any other government agency?*

YesNoUnsure At This Time
PLEASE NOTE: Faith Builders Day Care limits the number of children receiving CCIS and/or other government funded assistance at 5% of the total enrollment. If you currently receive assistance, plan to apply for assistance, or are unsure if you will seek assistance in the future, PLEASE CONTACT THE DAY CARE PRIOR TO SUBMITTING THIS FORM AND PAYING THE APPLICATION FEE.
Questions/Comments

Application Fee Payment

1 Child

$30.00

2 Children

$60.00

3 Children

$90.00

Total

$0.00

Credit Card

Should be Empty: