Registration Form
Full name of child
*
First Name
Middle Name
Last Name
Gender
*
Boy
Girl
Date of birth
*
-
Month
-
Day
Year
Date
Full name of child
First Name
Middle Name
Last Name
Gender
Boy
Girl
Date of birth
-
Month
-
Day
Year
Date
Parent/Guardian Name
*
First Name
Middle Name
Last Name
Relationship to Child
*
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Parent/Guardian Name
First Name
Middle Name
Last Name
Relationship to Child
Email
example@example.com
Phone Number
Please enter a valid phone number.
Person authorized to pick up
*
First Name
Last Name
Person authorized to pick up
*
First Name
Last Name
Person to call in case of emergency
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Relationship to child
Days of care
*
Monday
Tuesday
Wednesday
Thursday
Friday
Drop off/Pick up
*
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
My Products
*
prev
next
( X )
Deposit
Non Refundable deposit
$
50.00
Weekly Tuition
Monday-Friday (Deposit needed)
$
150.00
Drop in 1 day
Valid for one day
$
30.00
Cash App
Send your payment to our cash app $Ivysplace15
$
Free
Credit Card
Signature of parent
*
Signature of child care provider
Save
Submit
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