Enrollment Form

Entrance Date

Child Name

Date of Birth

Month

Day

Year

Age

Sex

Home Address

Father's Name

Father Phone

Father Address

Father Email

Father Place of Employment

Father Work Phone

Mother Name

Mother Phone

Mother Address

Mother Email

Mother Place of employment

Childs Living Arrangements

Both Parents

Mother

Father

Other

Child's Legal Guardian(s)

Both Parents

Mother

Father

Other

The child may be released to the person(s) signing this agreement or to the following:

Name

Address

Phone

Relationship to child

Name

Address

Phone

Relationship to child

Persons to contact in case of emergency when parent or guardian cannot be reached

Name

Phone

Name

Phone

Name

Phone

Name of School child attends, if any:

Child's Doctor or Clinic:

Doctor or Clinic Phone

My child has the following special needs:

The following special accommodation(s) may be required to most effectively meet my child’s needs while at the center:

My child is currently on medication(s) prescribed for long-term continuous use and/or has the following preexisting illness, allergies, or health concerns: