Child Care Enrollment Application
18 months and up
Mon – Fri 7:30 am – 5:30 pm
$100 Application Fee and $1,300/month
Information of Child
Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Female
Male
Parent/Guardian #1 Information
Name
First Name
Last Name
Relationship
Cell Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Place of Work
Parent/Guardian #2 Information
Name
First Name
Last Name
Relationship
Cell Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Place of Work
Emergency Contact
Name
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Information
Doctor's Name
First Name
Last Name
Doctor's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Dentist's Name
First Name
Last Name
Dentist's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred hospital
Insurance/health coverage
How does your child cope with difficult situations?
Please list any physical, medical, or other conditions of which we should be aware.
Religion(s) practiced at home:
Congregational affiliation:
Submit
Should be Empty: