Daycare Application Form
Child Name 1
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Gender
*
Boy
Girl
Ethnicity
*
Child Name 2
First Name
Last Name
Ethnicity
*
Date of birth
-
Month
-
Day
Year
Date
Gender
Boy
Girl
Child Name 3
First Name
Last Name
Gender
Boy
Girl
Date of birth
-
Month
-
Day
Year
Date
Child Name 4
First Name
Middle Name
Last Name
Gender
Boy
Girl
Date of birth
-
Month
-
Day
Year
Date
Child Name 5
First Name
Middle Name
Last Name
Gender
Boy
Girl
Date of birth
-
Month
-
Day
Year
Date
Child Name 6
First Name
Middle Name
Last Name
Gender
Boy
Girl
Date of birth
-
Month
-
Day
Year
Date
Child Name 7
First Name
Middle Name
Last Name
Gender
Boy
Girl
Date of birth
-
Month
-
Day
Year
Date
Mother's Name
*
First Name
Middle Name
Last Name
Ethnicity
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Date of birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Father's Name
*
First Name
Last Name
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Who has parental responsibility?
*
Mother
Father
Other
Please specify
Person authorized to pick up child
*
First Name
Middle Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Person to call in case of emergency
*
First Name
Last Name
Name
*
First Name
Middle Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Preferred Language
*
Back
Next
Questionnaire
What area does your child need improvement on? (For example: potty training, learning ABCs etc.)
Child favorite activity?
Preferred hospital
Child's favorite cartoon character?
Do you understand and accept the fees associated with being late or dropping off early?
*
Yes
NO
Do you understand and accept ALL PAYMENTS are due every Friday by 5:00pm
*
Yes
No
Do you understand and accept until DHS pays you are responsible for ALL cost associated with care?
*
Yes
No
DO you accept and understand that children will be transported in a insured vehicle with proper seating if need be?
*
Yes
No
Do you accept and understand that any holidays will result in out-of-pocket costs starting at an additional $50+? ( varying on amount of kids and hours needed)
*
Yes
No
DO you accept an ongoing fee monthly of $5 will be added to your bill once a month? (unless your child is over four years old)
*
Yes
No
Do you accept and understand that all rules of the house must be followed by all children?
*
Yes
No
Do you accept and understand that being 30 minutes late for drop off and pick up will result in an extra fee and cancellation of services?
*
Yes
No
Back
Next
Todays Date
*
-
Month
-
Day
Year
Date
Start Date
*
-
Month
-
Day
Year
Date
Signature of child care provider
Signature of parent
*
Submit
Should be Empty: