Enrollment Form
The Treasure Hunt ELC
Child's Information:
Child's Name
First Name
Last Name
DOB
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Please Select
Male
Female
Primary Language Spoken
Parent/Guardian Information
Mothers Name:
First Name
Last Name
Mother Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Father's Name:
First Name
Last Name
Father's Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Father's Email:
example@example.com
What Is the best way to reach Parent's
Phone
Email
Text
All
Emergency Contacts: (Other than parents/guardians)
Emergency Contact Name #1
First Name
Last Name
Relationship to Child:
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Address:
Emergency Contact Name #2
First Name
Last Name
Relationship to Child:
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Address:
Full Name:
First Name
Last Name
Relationship to Child:
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Additional Notes/Instructions (if any)
Authorized Pick-Up Person #2
Full Name:
First Name
Last Name
Relationship to Child:
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Additional Notes/Instructions (if any)
Childcare Program Information:
Program Type:
Full Day
Half Day
Other
Preferred Start Date:
-
Month
-
Day
Year
Date
Days of Attendance:
Monday
Tuesday
Wednesday
Thursday
Friday
Medical Care Provider
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.
Emergency Medical Care Provider
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.
Dental Care Provider
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.
Email
example@example.com
Drop-Off time
Hour Minutes
AM
PM
AM/PM Option
Pick-Up time
Hour Minutes
AM
PM
AM/PM Option
Emergency Medical Authorization
I hereby give permission for the Mouna’s Children Center facility to seek emergency medicalcare for my child in the event of an illness or injury.
*
YES
NO
Signature
Today's Date:
-
Month
-
Day
Year
Date
File Upload
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