• Child Enrollment Form

    Please complete the child, parent/guardian, sibling, enrollment, schedule, and payment details.

  • Child Information

  • Birth date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • The Creative Clubhouse LLC • thecreativeclubhouse.org

  • Parent/Guardian Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Parent/Guardian 1 Preferred Contact Method*
  • Does the child live with Parent/Guardian 1?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Parent/Guardian 2 Preferred Contact Method
  • Does the child live with Parent/Guardian 2?

  • Sibling Information

  • Does the child have siblings?*
  • Sibling details
  • Does this sibling live in the home?
  • Sibling care-requested

  • Family Communication

  • Preferred Communication Method
  • Are there any communication or accessibility needs?
  • Is there any additional information we should know?
  • How did you hear about us?*

  • Documents

  • Upload a File
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    Choose a file
    Cancelof
  • Upload a File
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  • Parent or Guardian Acknowledgments

  • Parent/Guardian 1 Information
  • The Creative Clubhouse LLC • thecreativeclubhouse.org
  • Parent/Guardian 2 Information
  • Please add one row per sibling if applicable.

  • Enrollment Request

  • Desired Start Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Enrollment Type*

  • Weekly Schedule

  • Monday - Care Needed*
  • Monday - Drop-off Time
  • Monday - Pickup Time
  • Tuesday - Care Needed*
  • Tuesday - Drop-off Time
  • Tuesday - Pickup Time
  • Wednesday - Care Needed*
  • Wednesday - Drop-off Time
  • Wednesday - Pickup Time
  • Thursday - Care Needed*
  • Thursday - Drop-off Time
  • Thursday - Pickup Time
  • Friday - Care Needed*
  • Friday - Drop-off Time
  • Friday - Pickup Time
  • Saturday - Care Needed*
  • Saturday - Drop-off Time
  • Saturday - Pickup Time
  • Sunday - Care Needed*
  • Sunday - Drop-off Time
  • Sunday - Pickup Time

  • Payment

  • Payment type*
  • Format: (000) 000-0000.
  • Subsidy start date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Upload a File
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  • Custody Restrictions

  • Are there any custody, guardianship, protective-order, visitation, or pickup restrictions?*
  • Restriction effective dates*
     - -
    2 digit month, 2 digit day, 4 digit year
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  • CPS or State Custody

  • Is the child involved in CPS, foster care, kinship care, or state custody?*
  • Custody arrangement
  • Format: (000) 000-0000.
  • Upload a File
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  • Emergency Contacts

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Emergency contact 1 pickup authorization*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Emergency contact 2 pickup authorization*

  • Authorized Pickup

  • Authorized pickup list*
  • Is there anyone who must never pick up the child?*

  • Childcare History

  • Has the child previously attended childcare?*
  • Dates attended*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Is the child currently enrolled elsewhere?*
  • Does the child have any current medical conditions?

  • Medical Information

  • Format: (000) 000-0000.
  • Has the child had any recent illness or hospitalization?*
  • Does the child have any physical restrictions?*
  • Does the child have any special healthcare needs?*

  • Allergies

  • Does the child have any allergies?*
  • Upload a File
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  • Medications

  • Does the child take medication?*
  • Listing medication does not authorize administration.
  • Does the child have any developmental concerns?*

  • Development and Support

  • Does the child have any diagnoses?*
  • Does the child have an IFSP / IEP?*
  • Does the child work with any specialists?*
  • Does the child need accommodations?*
  • Does the child have any triggers?*
  • Does the child need feeding help?*
  • Does the child have any food restrictions?*
  • Does the child have any cultural considerations?*

  • Special Services

  • Does the child receive special services?*
  • Upload a File
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  • Daily Routine

  • Is the child an infant?*

  • Infant Care

  • The Creative Clubhouse LLC • thecreativeclubhouse.org

  • Individual Permissions

  • Optional media permission is not required for enrollment and may be withdrawn in writing.
  • Emergency medical care permission*
  • Permission for local walking trips*
  • Permission for transportation if offered*
  • Permission for sunscreen application*
  • Permission for insect repellent application*
  • Permission for water play*
  • Permission for photos and videos for private family communication*
  • Permission for photos and videos for classroom displays*
  • Permission for photos and videos for website or social media*
  • The Creative Clubhouse LLC • thecreativeclubhouse.org
  • I certify that the information provided is true, complete, and accurate to the best of my knowledge. I understand that false or incomplete information may result in denial or termination of enrollment.*

  • Office Use Only

  • Enrollment Approved

  • Required Document Uploads

  • Upload ID
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  • Upload Records
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  • Signatures and Certification

  • Parent/Guardian 1 Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Parent/Guardian 2 Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • The Creative Clubhouse LLC • thecreativeclubhouse.org
  • The Creative Clubhouse LLC • thecreativeclubhouse.org
  • Is there a second parent/guardian?*

  • The Creative Clubhouse Enrollment Packet

    Thank you for choosing The Creative Clubhouse. This packet should take approximately 10–15 minutes to complete.
  • Play. Learn. Create. Grow.
  • Please have the following ready before you begin: your child's immunization record, birth certificate, insurance card, government-issued parent ID, and any applicable custody or medication documents.
  • Should be Empty:
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