Child Care Application

Information of Chid

Happy Kids Happy Parents
Child Care/Summer Camp Registration

Mama Tice one application per child
Program Choice

Weekly CareDrop In CareSummer CampOther
Child name*

First NameLast Name
Birth Date*

MonthDayYear
Age
Gender

FemaleMale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us*

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

6am to 6pm630am to 630pm730am to 730pmOther
Days of the week required*

MondayTuesdayWednesdayThursdayFriday
Do you require before or after school care?

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

First NameLast Name
Relationship*
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Place of Work*
Relationship
Name

First NameLast Name
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.
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 deposit to hold your child spot.

**Deposit much be paid for registration to be complete.
Should be Empty:

Information of Chid

Child Care/Summer Camp Registration

Information of Parent(s)

Medical Information