Agape Caring Hearts Childcare Ministry Pre-Registration Form

Pre-Registration Form
Welcome!

We are excited that you are interested in learning more about Caring Hearts childcare ministry and early learning center at Agape! We are busy preparing the center and expect to open in mid-June/early July serving 12 months to 5 years old. Please fill out this pre-registration form to be considered for one of our toddler, pre-kindergarten or Jump Start (school readiness program) openings. After this form is submitted and we are ready to enroll children, we will contact you to discuss your childcare needs and our philosophy.
Parent/Legal Guardian #1 Name*

First NameLast Name
Parent/Legal Guardian #2 Name

First NameLast Name
Child's Name*

First NameMiddle NameLast Name
Child's Birth Date*

MonthDayYear
Child's Gender*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary E-mail*
example@example.com
Parent/Legal Guardian #1 Phone*
Format: (000) 000-0000.
Preferred Start Date*
Preferred Care Schedule*
Preferred Payment Method*
Exceptional Childcare Needs (such as dietary, medical, etc.)
Additional Information
If not full-time, please indicate preferred schedule.
Should be Empty:

Pre-Registration Form