Child Care Application

Information of Chid

Happy Kids Happy Parents
Child Care/Summer Camp Registration

MaMaTice one application per child
Program Choice*

Weekly CareDrop In CareSummer CampOther
Child name*

First NameLast Name
Birth Date*

MonthDayYear
Age*
Gender*

FemaleMale
Tell me a little bit about your child I would love to hear about their likes dislikes. (food,activities etc)*
Does your child have and behavioral issues? If yes please explain below.*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us*

Facebook MarketplaceMamaTice FlyerMamaTice InstagramReferral
Referral Name
Hours of child care required (school hours are 6:00 am to 7:30pm)*

6am to 6pm630am to 630pm730am to 730pmOther
IExplain if other.
Days of the week required*

MondayTuesdayWednesdayThursdayFriday
Are you looking for long or short term care? Explain your answer. Week or 1yr etc....*
Do you require before or after school care?

Before schoolAfter schoolN/A
Information of Parent(s)
Mother*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Place of Work*
Father*
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Place of Work*
Who has parental rights

MotherFatherOther
Please specify
Emergency Contact 1
In the event of an emergency, please contact:
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email Address
example@example.com
Other people authorized to pick up child from school
Name*

First NameLast Name
Relationship
Phone Number*
Please enter a valid phone number.
Email Address
example@example.com
Other first and last names of people able to pick up your child.
Medical Information
Doctor's Name

First NameLast Name
Doctor's Phone Number
Please enter a valid phone number.
Preferred hospital
Insurance/health coverage
Dentist's Name

First NameLast Name
Dentist's Phone Number
Please enter a valid phone number.
Please list any of the following: Current medications, medication allergies, food allergies, chronic health concerns or additional care needs.*
Does this child have any special needs care needed? If so please explain.*

YesNoOther
Explain special care needs here.*
NA if None
Start Date*

MonthDayYear
Date
Parent signature

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Childcare provider signature

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Once you hit submit you will be sent instructions on where to pay required registration to secure your child spot.

Thank you!
Should be Empty:

Information of Chid

Child Care/Summer Camp Registration

Information of Parent(s)

Medical Information