Expected Entrance Date Date* Age Age* Birthdate Date* Hours of Care needed (Drop-off/Pick-Up) Time AM to Time PM
PLEASE NOTE: You are required to provide your child's immunization records, in addition to, filing out all of the information above.
Should (child's name)First Name* Last Name* Date of birth suffer an injury or illness while in the care of Caterpillars to Butterflies Inc. and the facility is unable to contact the parents immediately, it shall be authorized to secure such medical attention and care for the child as may be necessary. I (We) shall assume responsibility for payment for services.Parent/Guardian: Signature* Date: Date* Facility Director/Administrator/Person-In-Charge: Signature Date: Date