Our Enrollment Process

We are enrolling!

Child Enrollment and Authorization

Child Enrollment and Authorization

Child's Name

First Name

Last Name

Child's Nickname

Does Child Have Allergies

If yes list all allergies on the back side of the form

Child's Birthdate

MM

DD

YYYY

Date Entered Care

MM

DD

YYYY

1st Parent or Guardian Contact Information

Name

First Name

Last Name

Relationship to Child

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone

(###)

###

####

Home Phone (if different from home phone)

(###)

###

####

Email Address

Work Phone

(###)

###

####

Work Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

2nd Parent or Guardian Contact Information

Name

First Name

Last Name

Relationship to Child

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone

(###)

###

####

Home Phone (if different from cell phone)

(###)

###

####

Email Address

Work Phone

(###)

###

####

Work Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Required Emergency Contact Information

Emergency Contact Name 1

First Name

Last Name

Emergency Contact Phone 1

(###)

###

####

Relationship

Emergency Contact 2

Emergency Contact 2

First Name

Last Name

Emergency Contact Name 2

First Name

Last Name

Emergency Contact Phone 2

(###)

###

####

Relationship