• Butterfly Childcare

    Butterfly Childcare

    Enrollment Form
  • Proposed Start Date
     - -

  • Note:

    Please complete all the sections with the required information. Contact us if you have any questions while completing this form. You will be required to complete other supplementary forms and consent forms as a part of enrollment.

  • Personal Information

  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Emergency Contact

    Other than parents/guardian
  • Format: (000) 000-0000.
  • Authorized to Pick up your child?*
  • Format: (000) 000-0000.
  • Authorized to Pick up your child?

  • Authorized Person

    Please list the names to whom child can be released if different than the emergency contact

  • Enrollment Information

  • Any previous childcare experience?

  • Health Information

  • Format: (000) 000-0000.
  • Does your child have any disability or special needs? (Medications, treatments, allergies, food intolerance, conditions, behaviors, etc.)*
  • Any food restrictions or a special diet plan?*
  • Is your child using any medication or ongoing medication? If "YES', you need to fill out the medication authorization form.*
  • Do you have any concerns regarding your child's development?*

  • Consent for Emergency Medical Treatment

  • As a parent/guardian I hereby....*

  • Enrollment and Policy Agreement

    Please go through the list and check if you agree
  • Butterfly Childcare Policy and Procedure Agreement*

  • Portable Emergency: Butterfly Childcare

  • Date of Birth*
     - -

  • Health and Medical Information

  • Any Allergies or food restriction?*
  • Any ongoing medication?*
  • Immunization Up to date?*

  • Parent/Guardian's Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Emergency Contact

    (Other than parents/guardians)
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Parent/Legal Guardian Consent and Agreement for Emergencies*
  • Should be Empty: