Enrollment Form

This field is for validation purposes and should be left unchanged.

Date of Birth(Required)

Child's Home Phone Number(Required)

Date of Admission(Required)

Mother's Date of Birth

Mother's Cell/Home Phone Number

Mother's Work Phone Number

Mother's Email Address

Father's Date of Birth

Father's Cell/Home Phone Number

Father's Work Phone Number

Father's Email Address

Please Attach a current copy of your court order.(Required)

Max. file size: 100 MB.

Emergency Contact and Authorization to pick up

Please list 3 local individuals to contact in the event of an emergency

School Age Children

My child attends the following school:

Parent or Legal Guardian Signature

Authorization for Emergency Medical Attention

In the event I cannot be reached to make arrangements for emergency medical care, I authorize the person in charge to take my child to:

Emergency Medical Care Facility

Attendance

My child will normally be in attendance the follow days and times:

Special Needs

List any special problems that your child may have, such as allergies, existing illness, previous serious illness, injuries and hospitalizations during that past 12 months, and medication prescribed for long-term continuous use, and any other information which caregivers should be aware of:

If not applicable, initial here

Photo Release

From time to time our facility may take photographs for educational use. I give consent for the facility to take photographs of my child.

Outside Employment

I understand that the staff at this facility are prohibited in participating in outside employment with parents.

Social Networking

I understand that the staff at this facility are prohibited in participating in social networking activities with parents and children enrolled at the facility. (Such as Facebook, MySpace, and Twitter)

Enrollment Application