Mino Bimaadiziwin Child Care Center
Enrollment Form
Child's Full Name
*
First Name
Middle Name
Last Name
Child's DOB
*
-
Month
-
Day
Year
Date
What is child's current age?
*
Child's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
1st Parent/Legal Guardian's Full Name
*
First Name
Middle Name
Last Name
Relationship to Child
Does child live with 1st Parent/Guardian?
Please Select
Yes
No
Part-time
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Preferred Method of Contact
Please Select
Email
Text
Phone Call
Okay to leave a message?
Please Select
Yes
No
1st Parent/Guardian's Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
2nd Parent/Legal Guardian's Full Name
*
First Name
Middle Name
Last Name
Relationship to Child
*
Does child live with 2nd Parent/Guardian?
Please Select
Yes
No
Part-time
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
Preferred Method of Contact
Please Select
Email
Text
Phone Call
Okay to leave a message?
Please Select
Yes
No
2nd Parent/Guardian's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact #1:
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact #2:
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Authorized Person to Pick-up Child
*
Authorized Person to Pick-up Child
*
Allergies? If yes, please fill out 'Allergy Information Form' in Enrollment Packet (See form below)
*
Please Select
Yes
No
Food Restrictions? If yes, attach Doctor's Note -->
*
Please Select
Yes
No
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Days requesting child care
*
Monday
Tuesday
Wednesday
Thursday
Friday
Time period requesting child care (please specify exact day with times)
*
Court Order? If yes, attach copy -->
*
Please Select
Yes
No
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
PHOTO AND VIDEO CONSENT AND RELEASE
Mino-B Child Care Center utilizes photos/videos taken at Mino-B Child Care Center for marketing, program updates and print material. Do you give permission to Mino-B Child Care Center to utilize your child's photos/videos for marketing, program updates and print material?
Please Select
I do give permission for my child's photos/videos to be taken
I do not give permission for my child's photos/videos to be taken
Print Name
*
Sign Name
*
Today's Date
*
-
Month
-
Day
Year
Date
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Mino Bimaadiziwin
ALLERGY INFORMATION - Please fill in/skip if not applicable
Child's Name
First Name
Last Name
My Child is Allergic to:
What happens when exposed?
Please provide Doctor's Note for special accommodations:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Doctor's Name
Doctor's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Hospital/Notes
Print Name
Signature
Today's Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: