Giggles & Wiggles Daycare Application
Full name of child (1)
First Name
Middle Name
Last Name
Gender
Boy
Girl
Date of birth
-
Month
-
Day
Year
Date
Full name of child (2)
First Name
Middle Name
Last Name
Gender
Boy
Girl
Date of birth
-
Month
-
Day
Year
Date
Mother's Name
First Name
Middle Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Father's Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Who has parental responsibility?
Mother
Father
Other
If Other is selected please specify
Alternate person authorized to pick up child (1)
First Name
Middle Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate person authorized to pick up child (2)
First Name
Middle Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Person to call in case of emergency if Parent cannot be reached
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Signature of parent
Submit
Submit
Should be Empty: