ENROLLMENT APPLICATION FORM
STUDENT INFORMATION
Name
*
First Name
Last Name
DATE OF BIRTH
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
GENDER
*
PRIMARY LANGUAGE
*
ADDRESS
FULLY POTTY TRAINED? (If applicable)
ELEMENTARY SCHOOL ATTENDING? (If school-age)
DESIRED START DATE
*
DAYS NEEDED FOR CARE (M, TU, W, TH, F)
*
WHERE DID YOU HEAR ABOUT US?
PARENT/GUARDIAN INFORMATION
NAME OF PARENT/GUARDIAN #1
*
PHONE NUMBER OF PARENT/GUARDIAN #1
*
Please enter a valid phone number.
Format: (000) 000-0000.
EMAIL OF PARENT/GUARDIAN #1
*
example@example.com
OCCUPATION OF PARENT/GUARDIAN #1
*
RELATIONSHIP TO CHILD
*
NAME OF PARENT/GUARDIAN #2
PHONE NUMBER OF PARENT/GUARDIAN #2
Please enter a valid phone number.
Format: (000) 000-0000.
EMAIL OF PARENT/GUARDIAN #2
example@example.com
OCCUPATION OF PARENT/GUARDIAN #2
RELATIONSHIP TO CHILD
Signature
*
DATE
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
SUBMIT
SUBMIT
Should be Empty: