Enrollment Application

Enrollment Application

Early Childhood & Care for Toddlers & Preschoolers
Thank you for your interest in applying at Little Rivers Christian Learning Center. Please fill out this form completely, if a question does not apply to your child, write N/A (not applicable). New applications will be reviewed in the order it was recieved. Any updates regarding the status of your application will be sent to the primary cargeiver's email. If any of the information changes, please contact the center.
Before you begin your application, please answer the following questions:
What program are you looking to enroll?*
Are you enrolling with a private contract or child care voucher?*

Health Information

Please provide the following health information for the child.
Physician's Name*
Address*
Street, city, state and zip code
Phone Number*
Known Allergies*
Special Diets/Restrictions*
Chronic Health Conditions*
Does your child require routine or emergency care treatment for their health condition?*

YesNo

Emergency Contacts

In the event of an emergency when you can not be reached, the learning center may contact the following individuals whom are also authorize to take your child from the child care premises in cases of emergency. Contacts listed must be able to provide transportation. Note: Please do not list yourself or a parent as a contact.
1) Name (Please do not list parent as a contact.) *

First NameLast Name
Relationship to Child*
Address*
Street, City, State and Zip Code
Contact Number*
2) Name (Please do not list parent as a contact.) *

First NameLast Name
Relationship to Child:*
Address*
Street, City, State and Zip Code
Contact Number*

Transportation Plan/ Authorized Pick-up

Please let us know how your child will be arriving and departing the center.
My child will arrive to the program by:*

Parent Drop-offPublic BusPrivate Transportation Provided by Parent
My child will depart the program by:*

Parent Pick-upPublic BusPrivate Transporation Provided by Parent
In the space below, please note any important information regarding transportation of your child to and from the program (i.e. indicate who will be supervising children during transport or prior to their arrival at home/program who will be placing/receiving the child to and from the van/bus, etc.)
Authorized Pick-Up

I additionally authorize the following individual to take my child from the child care premises. (Please let me know at the beginning of the day when your child will be picked up by one of the authorized individuals.)
1) Name*

First NameLast Name
Relationship to Child*
Address*
Street, City, State and Zip Code
Contact Number*
2)Name*

First NameLast Name
Relationship to Child*
Address*
Street, City, State and Zip Code
Contact Number*

Anticipated Days & Time of Attendance

Hours of Operation 8:00 am - 5:00 pm
Days of Attendance*

MondayTuesdayWednesdayThursdayFriday
We offer a 9 hour care limit per day, to ensure that our staff to children ratio is always met. When selecting an arrival and depature time, please ensure that the hours selected do not exceed 9 hours. Our center is open for arrivals between 8-9am.
Arrival Time*

Hour Minutes

AM/PM Option
Departure Time*

Hour Minutes

AM/PM Option
If your child's attendance is expected to be different on some days, please specify what that schedule will be like down below.
Will copies of custody agreements, court orders, restraining orders be provided?*

YesNo
If yes, please provide a list of court or custody documents that we will be receiving from you.

Child’s Demographics