WeVillage LA | Full-Time Program Inquiry Form

Enrollment Registration Form

Child Information
Name of Child (First, Middle Initial, Last):*

First NameMiddle NameLast Name
Start Date*

MonthDayYear
Date
Select Your Village (Location)*
Please Select Your Program*
Is the child enrolled in childcare or school? If no, we require full immunization records*

YesNo
Date of Birth*

MonthDayYear
Date
Child’s Primary Language: *
Parent/Guardian’s Primary Language:
Home Email Address:*
example@example.com
Home Phone:*

Area CodePhone Number
Child’s Home Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian Marital Status:

SingleMarriedDivorcedWidowed
Primary Residence:*

MotherFatherBothGuardian
List the family members your child lives with—include names and ages of siblings:
Allergy Alert: Does child have allergies?*

YesNo
If yes, please list:
Immunization Records*

Browse Files

Cancelof
Parent's Information

Guardian(s) of the child(ren)
Parent Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Employer*
Employer Work Hours*
Work Email:*
example@example.com
Emergency Contact Information

Person other than parent/guardian who is authorized to pick up child
Please list the persons you would like contacted (in order of priority) if you cannot be reached in case of emergency. We will not release a child to anyone (other than the parent) under the age of eighteen (18), including siblings. Additionally, please list the persons you would like to be authorized for pick-up only on a given day (i.e., babysitter). For the safety of your child, we will request all authorized release persons with whom staff are not familiar to provide government-issued photo identification at the time of pick-up. You may also be required to complete state specific emergency release forms required by individual state child care licensing regulations.
Emergency Contact (1) Name:*

First NameLast Name
Emergency Contact (1) Relationship:*
Emergency Contact (1) Phone Number*

Area CodePhone Number
Emergency Contact (2) Name:*

First NameLast Name
Emergency Contact (2) Relationship:*
Emergency Contact (2) Phone Number*

Area CodePhone Number
Parent or Guardian Authorization

By signing below, you give WeVillage permission for the following:
- My child may be taken on field trips or excursions by bus or streetcar, as well as on neighborhood walks under required supervision.
- My child may participate in water play at local parks.
- My child may be given non-prescribed medication as indicated on the container. This may include sunscreen, antibacterial first aid cream, and diapering ointment. Prescription medications must be current and a permission slip is required for each medication.
- In an emergency, the childcare facility has my permission to call an ambulance, or take my child to any available physician or hospital at my expense to obtain medical treatment. In most emergencies, 911 is called and the child is transported to the nearest hospital and treated by the on-call physician. The parent or guardian of the child is notified as soon as possible.
Parent/Guardian Signature*

Clear
Child Enrollment & Authorization

Children’s Emergency Consent Information
If your child needs emergency medical care and you aren’t available to give formal consent to medical authorities, care may be unnecessarily delayed. All children under the care of WeVillage must have a completed Emergency Consent Form on file; in the event of a medical emergency, this form will accompany your child to the hospital.
I/we hereby authorize WeVillage to give consent for all medical and/or surgical treatment that may be required for our child/children during our absence.
Child's Medical History
Any Chronic Illness?*

YesNo
If yes, please explain
List any allergies, or type "N/A" if none.*
List any medications, or type "N/A" if none.*
Date of last tetanus shot*

MonthDayYear
Date
Doctor & Dental Information
Physician:*
Physician Telephone:*

Area CodePhone Number
Health Insurance Co.:
Member/Group No.:
Policy Holder Name:
Policy Holder DOB:
Dentist:*
Dentist Telephone:*

Area CodePhone Number
Health Insurance Co.:
Member/Group No.:
Policy Holder Name:
Policy Holder DOB:
Please check all the following and then sign at the bottom. *
Agreement
Parent’s signature:*

Clear
Bank Name:*
Exact Name on Bank Account*

First NameLast Name
Routing Number:*
Account Number:*
I understand that there is a $200 Refundable Deposit (not applicable to flexcare) + $250 Enrollment Fee. And, I authorize WeVillage to store my CC on file for fees associated with my care.
Monthly tuition is due ACH electronic check*

*Please initial each statement. Clear
There is a 3% fee for all CC charges for anything other than flexcare.
Date:*

MonthDayYear
Date
Should be Empty:

Enrollment Registration Form

Parent's Information

Emergency Contact Information

Parent or Guardian Authorization

Child Enrollment & Authorization

Child's Medical History

Agreement