Enrollment

First Name *

Last Name *

Date of Birth *

Age *

Gender

First Name *

Last Name *

Relationship to Child *

Phone Number *

Email Address *

Home Address *

First Name

Last Name

Relationship to Child

Phone Number

Email Address

(Someone other than parents/guardians)

Full Name *

Relationship *

Phone Number *

Email Address

Desired Start Date *

Program *

Schedule Type *

Full-Time (7:00 AM - 6:00 PM)

Part-Time (Half Day)

Custom Schedule (Please specify below)

Custom Schedule Details (if applicable)

Pediatrician Name

Pediatrician Phone

Allergies (Food, Medicine, Environmental) *

Current Medications

Medical Conditions/Special Needs

Dietary Restrictions/Preferences

Is there anything else you'd like us to know about your child?

How did you hear about us?

I certify that all information provided is accurate and complete. *

I have read and agree to the center's policies and procedures. *

Parent/Guardian Signature (Type Full Name) *

Date *