Childcare Enrollment Form
Child’s Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Age
Preferred Start Date
-
Month
-
Day
Year
Date
Parent/Guardian Information:
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Child
Additional Information
Does your child have any allergies or medical conditions?
Yes
No
If yes, please explain
Is your child potty trained?
Yes
No
In Progress
Days Needed
Full-Time (M–F)
Part-Time
Other
Medical History
Allergies or Medical Conditions
Yes
No
If yes, please explain:
Current Medications:
Physician Name:
Physician Phone:
Preferred Hospital:
Photo Consent
I give permission for Lil Ummi STEAM Academy to use photos or videos of my child for internal use, classroom documentation, and promotional materials including social media and the school website.
Yes
No
I give permission for my child to be transported by Lil Ummi STEAM Academy staff for authorized field trips or emergency purposes.
Yes
No
I understand and agree that my child will participate in age-appropriate STEAM (Science, Technology, Engineering, Arts, and Math) activities and experiments that support hands-on learning and development.
Yes
No
Signature
Date
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: