Childcare Application
(please fill out the entire application)
Childs Full Name
First Name
Last Name
Nick Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Enrollment
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Mothers Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Fathers Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Mother's Employer
Mother's Employer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Father's Employer
Employer's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Number of Days Child Need Care
I will drop off at? (add the time you will drop off your child)
Hour Minutes
AM
PM
AM/PM Option
I will pick up at? (add the time you will pick up your child)
Hour Minutes
AM
PM
AM/PM Option
Emergency Contact Name
First Name
Last Name
Relationship to the Child
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Is your child potty trained?
Yes
No
If answer no, have you started the process?
Yes
No
There will be a $100 enrollment fee due the same day you register you child(ren) *Nonrefunable*
AGREE
Parent Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Provider Signature
Submit
Submit
Should be Empty: