Child Care Enrollment Registration
The White House PA Academy
Today's Date
*
-
Month
-
Day
Year
Date
CHILD INFORMATION
Child's Name
*
First Name
Last Name
Middle Initial
Child's Birthdate
*
-
Month
-
Day
Year
Date
Gender
Female
Male
PARENT'S CONTACT
Mother's Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company Name
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Father's Name
*
First Name
Last Name
Father's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company Name
Father's Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Father's Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
EMERGENCY CONTACT 1
Name
*
First Name
Last Name
Relationship to Child
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
EMERGENCY CONTACT 2
Name
*
First Name
Last Name
Relationship to Child
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
SERVICE INFORMATION
Beginning Service Date
*
-
Month
-
Day
Year
Date
Hours of child care required (school hours are 7:00 am to 5:30 pm)
*
Full Day
Half Day Morning
Half Day Afternoon
Days Services are needed.
*
Monday
Tuesday
Wednesday
Thursday
Friday
Estimated drop off time
*
Hour Minutes
AM
PM
AM/PM Option
Do you require before or after school care?
Before Care
After Care
Both
CHILD'S HEALTH INFORMATION
Child's General Health (Does your child have any medical conditions which I should be made aware of?
*
Does your child have allergies?
*
Yes
No
If yes please list all their allergies below
Is your child immunizations up to date
*
Yes
No
Are there any food restrictions?
Has your child had the following common childhood illnesses? .(please check)
*
Constipation
Convulsions
Asthma
Bronchitis
Diarrhea
Fainting Spells
Frequent Colds
Frequent Ear Infections
Frequent Sore Throats
Lice
Ringworm
Skin Rash
Stomach Upset
Urinary Problems
Worms
Chicken Pox
Diabetes
Heart Disease
Hepatitis
Impetigo
Measles
Mumps
German Meales
Pollo
Scarlet Fever
Tuberculosis
Whooping Cough
Doctor's Name
*
Doctor's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Does your child have any speech, hearing or visual problems?
*
Would there be any restrictions to play or activities?
*
Dentist Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
ABOUT YOUR SCHOLAR
Has your child ever been in child care before?
*
Yes
No
What type of service
*
Center
Family
Daycare
None
Why are you looking for child care?
*
Are there any recent traumatic situations the child has been exposed to such as a death in the family, divorce, new sibling etc.?
*
Yes
No
If so. Please explain
What is your child's temperament? Are they easy going, hard to please, demanding, aggressive, etc.
*
What is your child's favorite food?
*
What is your child's lease favorite food?
*
OTHER FAMILY MEMBERS
Are there any siblings?
*
Yes
No
List all the siblings Names, Age & Gender
PAYMENT INFORMATION
Yearly Enrollment Registration Fees is $75 per child. Payments must be made before your child can be consider registered at The White House PA Academy. Child care tuition is due at the beginning of each week unless other arrangements are made with the director.
THANK YOU
All of us at The White House PA Academy thanks you for choosing us. We are excited to begin providing high quality care to your scholar.
PARENT AGREEMENT & SIGNATURE
Signature
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