Enrollment form

1Child

2Parent

3Emergency Contacts

4Health

5General

6Program Contract

Emergency Contacts
Emergency contact to notify if the parents/guardians cannot be reached.
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Relationship to Child*
Phone
Cell*
Authorized to pick up child?
- Yes
This person can only pick up your child with further written consent
2nd Emergency Contact
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Relationship to Child*
Phone
Cell*
Authorized to pick up child?
- Yes
This person can only pick up your child with further written consent
3rd Emergency Contact
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Relationship to Child*
Phone
Cell*
Authorized to pick up child?
- Yes
This person can only pick up your child with further written consent

Program Contract
What school are you applying for?*
How many days per week do you need childcare?*
Drop off time (hours of care)*

: Hours

Minutes

AM/PM

What time will you drop off your child to school?
Pickup time (hours of care)*

: Hours

Minutes

AM/PM

What time will you pickup your child from school?
What classroom would you like to enrol your child in?
*Rates are weekly and can vary based on co-pays/sliding scales
What classroom would you like to enrol your child in?
*Rates are weekly and can vary based on co-pays/sliding scales
I attest that the information I provided is true.*
- I attest that the information I provided is true. By signing below I agree to the terms of the information that was provided to me in the Parent Information/Rate Sheet, and I understand all of what I have read and signed

Your Child