Growing Prodigies Enrollment Form

Growing Prodigies Enrollment Form

Please complete this form to enroll your child in our daycare services. All information is kept confidential and is required for your child's safety and care.
Child's Full Name*

First NameLast Name
Birthdate
Gender
Full-time (40+ hrs/week)Part-time (20-40 hrs/week)Drop-in Care (less than 20 hrs/week)Daytime (6am-6pm)Afternoon/Evening Care (2pm-11pm)Overnight Care (6pm-6am)Weekend Care
Mother's Full Name*

First NameLast Name
Mother's Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Mother's Email Address
example@example.com
Father's Full Name*

First NameLast Name
Father's Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Father's Email Address
example@example.com
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
MotherFatherBoth ParentsOther (please specify)
Child's Medical Information (medications, health concerns, etc.)
Child's Doctor Name*

First NameLast Name
Doctor's Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
List any allergies or medical conditions
Emergency Contact

Must be 18 years or older
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to child
Should be Empty:

Emergency Contact