PART B: ENROLLMENT FORM FOR PARENT/CARETAKER FOR LEGALLY EXEMPT GROUP CHILD CARE PROGRAM

Whedco Form for Ages 3-5
Parent/Caretaker Information:
Parent's First Name*
Parent's Last Name Please include any ALIASES or MAIDEN names in parentheses*
MI
Suffix
Date of Birth*

MonthDayYear
Date
Gender*
Home Phone Number
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Home Address Street Address*
Apt/Fl - Mark N/A if not applicable*
City*
State*
Zip Code*
County (eg. Kings)*
Mailing Address: Street Address/P.O. Box

Same as above
Mailing Address: Street Address/P.O. Box
AptFI
City
State
Zip Code
SECTION 3: Children Receiving Child Care Assistance (Ages 3-5)
Daughter #1 First Name*
Daughter #1 Last Name*
MI
Date of Birth*

MonthDayYear
Date
Daughter #2 First Name
Daughter #2 Last Name
MI
Date of Birth

MonthDayYear
Date
Daughter #3 First Name
Daughter #3 Last Name
MI
Date of Birth

MonthDayYear
Date
Daughter #4 First Name
Daughter #4 Last Name
MI
Date of Birth

MonthDayYear
Date
Daughter #5 First Name
Daughter #5 Last Name
MI
Date of Birth

MonthDayYear
Date
SECTION 4: Parent/Caretaker Certification To the best of my knowledge, I hereby affirm that the information provided on Part B of this form is true and complete. I understand that the information is subject to verification and that making a materially false statement or affirmation may result in denial or termination of the enrollment, social services terminating child care assistance payments, and/or legal action against the parent/caretaker for deliberately presenting false or misleading information. Signature of Parent/Caretaker:Date:
Signature of ParentCaretaker*

Clear
Date*

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Should be Empty:

Whedco Form for Ages 3-5