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Enrollment Form
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Preferred Start Date
Date
Time
Hours of Daycare Required
Mornings
Afternoons
Full Day
Days Required
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Parent Account Details
Parent/Guardian Name
*
First
Last
Does/do the child(ren) live with you full time?
Yes
No
Address
Address Line 1
Address Line 2
City
State / Province / Region
Phone
Parent Photo
Click or drag a file to this area to upload.
Emergency Contact Name
*
First
Last
Emergency Contact Phone
*
Student Details
Name
*
First
Last
Date of Birth
Gender
Male
Female
Student's Doctor's Name
*
First
Last
Student Health Insurance Company
Student's Doctor's Phone
*
Is anyone besides you allowed to pick up your child?
*
Yes
No
Photos of those allowed to pick up your child:
*
Click or drag a file to this area to upload.
Please let us know about any behavioral concerns:
Parent Student behavioral
Please let us know about any medical concerns:
Please let us know about any allergies:
Link to Contract Can be Placed Here
Checkboxes
*
I acknowledge that I have read, understood, and agree to the terms and conditions outlined in the contract
Parent/Guardian Signature
Clear Signature
Submit
