Daycare Application Form
Please complete this application to enroll your child in our daycare program.
Child Information
Please provide details about the child applying for daycare.
Child's Full Name
*
First Name
Last Name
Child's Age
*
Child's Race/Ethnicity
*
Please Select
White
Black or African American
Hispanic or Latino
Asian
Native American or Alaska Native
Native Hawaiian or Pacific Islander
Other
Upload Child's Shot Records
*
Upload a File
Drag and drop files here
Choose a file
Cancel
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Preferred Daycare Location
*
Please Select
Downtown Center
Northside Center
Eastside Center
Westside Center
Other
Parent/Guardian Information
Please provide information about the parent or guardian.
Parent/Guardian Full Name
*
First Name
Last Name
Parent/Guardian Age
*
Employment Status
*
Employed Full-Time
Employed Part-Time
Unemployed
Self-Employed
Student
Other
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email Address
*
example@example.com
Submit Application
Should be Empty: