Enrollment Application

Start Date

MonthDayYear
Date
Child's Full Name

First NameLast Name
Child's Date of Birth

MonthDayYear
Date
Mother Full Name

First NameLast Name
Father Full Name

First NameLast Name
Guardian Full Name

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

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact 1 Name

First NameLast Name
Emergency Contact 1 Relationship
Emergency Contact 1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact 2 Name

First NameLast Name
Emergency Contact 2 Relationship
Emergency Contact 2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Authorized Pick-Up Persons (Other than Parent/Guardian)
Physician / Medical Facility Name
Dentist Name
Dentist Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Dentist Phone
Please enter a valid phone number.Format: (000) 000-0000.
Physician / Medical Facility Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Physician / Medical Facility Phone
Please enter a valid phone number.Format: (000) 000-0000.
Does your child have any allergies or medical conditions?
List any medications your child is currently taking
Special instructions or notes for our staff
Program requested
Days attending
Drop-off time

Hour Minutes

AM/PM Option
Pick-up time

Hour Minutes

AM/PM Option
Upload immunization records

PDF or image files, max 10 MB
Cancelof
Upload birth certificate

PDF or image files, max 10 MB
Cancelof
E-signature

Sign using your mouse, trackpad, or finger
Should be Empty: