Daycare Application Form

Daycare Application Form
Full name of child

First NameMiddle NameLast Name
Gender

BoyGirl
Date of birth

MonthDayYear
Date
Please list any known food allergies *
Mother's Name

First NameMiddle NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you need extended care like (late pickup or weekends?)

Before SchoolAfter SchoolSecond or Third ShiftWeekend Hours
Who has parental responsibility?

MotherFatherOther
Please specify
Person authorized to pick up child

First NameMiddle NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Person to call in case of emergency

First NameLast Name
Name

First NameMiddle NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
What type of payment options do you use for childcare services
Signature of child care provider
Signature of parent
Should be Empty: