Daycare Application Form

Daycare Application Form

Smalls and Smiles Home Daycare
Providing your child with the best possible care while supporting development and growth.
Full name of child

First NameMiddle NameLast Name
Gender

BoyGirl
Date of birth

MonthDayYear
Date
Age of child
Mother's Name

First NameMiddle NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father's Name

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who has parental responsibility?

MotherFatherBoth Mother and fatherOther
Please specify
Part-Time or Full-time?

Part-timeFull-timeHalf days (1 to 5 hours)Before and after school

When would you need daycare?

What time is the earliest and the latest time that you will need childcare for?
Any other information about your schedule?Will it be the same every week? If you have a different schedule every week please explain:
Any allergies?
Any health concerns?
Any disabilities?
The daily fee for full day childcare is $40

The daily fee for before and after school is $20

All meals and snacks included

Due, and payable on the Friday of each week of care.
When would you like to start?

MonthDayYear
Date
Signature of child care provider

Clear
Signature of parent

Clear