Plinke's Little Explorers Enrollment Application

Plinke's Little Explorers Enrollment Application

Thank you for your interest in Plinke's Little Explorers! Please complete all information to enroll your child.
CHILD INFORMATION
Child's Full Name

First NameLast Name
Preferred Name (if different)
Date of Birth

MonthDayYear
Date
Gender
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Primary Language Spoken at Home
Child lives with

Other
Does your child have any siblings enrolled with us?
If yes, please list their names and ages
PARENT/GUARDIAN INFORMATION
Parent/Guardian #1 Name

First NameLast Name
Relationship to Child (Parent/Guardian #1)
Phone (Parent/Guardian #1)
Please enter a valid phone number.Format: (000) 000-0000.
Email (Parent/Guardian #1)
example@example.com
Address (if different) (Parent/Guardian #1)
Parent/Guardian #2 Name

First NameLast Name
Relationship to Child (Parent/Guardian #2)
Phone (Parent/Guardian #2)
Please enter a valid phone number.Format: (000) 000-0000.
Email (Parent/Guardian #2)
example@example.com
Address (if different) (Parent/Guardian #2)
EMERGENCY CONTACTS (Other than parents/guardians)
Emergency Contact #1 Name

First NameLast Name
Relationship (Emergency Contact #1)
Phone (Emergency Contact #1)
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact #2 Name

First NameLast Name
Relationship (Emergency Contact #2)
Phone (Emergency Contact #2)
Please enter a valid phone number.Format: (000) 000-0000.
CHILD CARE INFORMATION
Desired Start Date

MonthDayYear
Date
Days Needed
Hours Needed
From

Hour Minutes

AM/PM Option
To

Hour Minutes

AM/PM Option
Care Type
How did you hear about us?
HEALTH INFORMATION
Does your child have a pediatrician?
Pediatrician Name
Pediatrician Phone
Please enter a valid phone number.Format: (000) 000-0000.
Does your child have any allergies?
If yes, please explain
Does your child have any medical conditions we should be aware of?
If yes, please explain
AUTHORIZATION & AGREEMENT
I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that this application does not guarantee enrollment. I agree to follow the policies and procedures of Plinke's Little Explorers.
Parent/Guardian Signature
Date

MonthDayYear
Date
Should be Empty:

Plinke's Little Explorers Enrollment Application

CHILD INFORMATION

PARENT/GUARDIAN INFORMATION

EMERGENCY CONTACTS (Other than parents/guardians)

CHILD CARE INFORMATION

Hours Needed

HEALTH INFORMATION

AUTHORIZATION & AGREEMENT