Childcare Center Pre-Registration Form

Childcare Center Pre-Registration Form
Pre-Registration Form

Please fill out this pre-registration form to be considered for one of our childcare spots. After this form is submitted, we will contact you to schedule an interview to meet your lovely family! We will discuss your childcare needs and our philosophy.
Parent #1 Name*

First NameLast Name
Parent #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
Secondary E-mail
(optional)
Preferred Start Date
Parent #1 Primary Phone Number*
Location*
Parent #2 Primary Phone Number
Preferred Care Schedule*
Payment Type

Private PayTWC Childcare SubsidyMilitary Childcare Subsidy
Exceptional Childcare Needs
Additional Comments
If not full-time, please indicate preferred schedule.
Should be Empty: