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Highland Children's House
Please submit the Child Application form below to apply for child enrollment at Highland Children's House. Please submit a separate form for each child. Submitting this form does not register your child. We will contact you after your form is received. For information on availability and rates, please call us at 540-438-1100.
Child's Information
Name:
*
First Name
Middle Name
Last Name
Nickname: (enter N/A if none)
*
Date of Birth:
*
-
Month
-
Day
Year
Sex:
*
Home Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone:
*
Chronic Physical Problems/Pertinent Developmental Information/Special Accommodations Needed: (enter N/A if none)
*
Location for Enrollment:
*
Monterey
Bath
Either
Days of week and times of care needed:
*
When would you want to start care?: (i.e.- August 2023)
*
Previous Child Day Care Programs and Schools Attended: (enter N/A if none)
*
If Child attends this Center and another Program/School, give name of Program/School: (enter N/A if none)
*
Grade: (enter N/A if none)
*
If you are submitting multiple applications for additional children, please list the child's name(s) and age(s) below:
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Parent(s)/Guardian(s)
Who has legal custody of the child? (can select more than one)
*
Mother
Father
Other
Mother's Name:
*
First Name
Last Name
Mother's Home Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mother's Place of Employment:
*
Mother's Business Phone:
*
Mother's Home Phone:
*
Mother's Cell Phone:
*
Mother's Email Address:
*
Father's Name:
*
First Name
Last Name
Father's Home Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Father's Place of Employment:
*
Father's Business Phone:
*
Father's Home Phone:
*
Father's Cell Phone:
*
Father's Email Address:
*
Person(s) or Agency Having Legal Custody of Child:
*
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone:
*
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Emergency Information
Allergies or Intolerance to Food, Medication, etc., and Action to Take in an Emergency: (enter N/A if none)
*
Child's Physician (list name, address, and phone):
*
Person #1 to contact if Parent(s)/Guardian(s) cannot be reached (list name, relationship, address, and phone):
*
Person #2 to contact if Parent(s)/Guardian(s) cannot be reached (list name, relationship, address, and phone):
*
Person(s) Authorized To Pick Up Child:
*
Person(s) NOT Authorized To Pick Up Child:
*
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Agreement
By signing and clicking Submit, I certify the information entered on this enrollment application is true and accurate. I also understand submitting this form does not guarantee enrollment. We will contact you after your form is received. For information on availability and rates, please call us at 540-438-1100. Thank you!
Your Full Name:
*
Your Email Address:
*
Your Phone Number:
*
Today's Date:
*
-
Month
-
Day
Year
Submit
Should be Empty: