Registration application

Child Care Registration Application for Enrollment. It takes about ten minutes. Everything you write goes only to the center.

Your children

One section per child. We are only accepting full-time applicants at this time.

Primary guardian

The person we should contact first.

First name

Last name

Relationship to the child Home address

City

State

ZIP code Personal phone Email address Employer optional Employer address optional Work phone optional

Medical

I hereby grant permission for the staff of this facility to contact the following medical personnel to obtain emergency medical care if warranted.

Doctor Address Phone Second doctor optional Address optional Phone optional Hospital preference Diet restrictions Special health, exercise or sleep requirements Known allergies or medical problems Medication

If your child needs medicine, please give the name, the dose, the symptoms that mean it is needed, when it is given, how it is stored and its shelf life.

Helpful information about your child

Anything that helps us look after them well. Please say if your child is potty training.

Payment type

How will care be paid for?

Sign

Sign with your finger. By signing you confirm that what you have written here is true and complete as far as you know.

Your full name Signature

Sign here

Once you send this, the Director reviews it and two Directors sign it. We will let you know either way.