We are interested in enrolling the following child(ren):
Name:______________________________________Date of Birth:_________________________
Name of Previous Day Care / School:____________________Language spoken at home:__________
Home Address:___________________________________________________________________
_______________________________________________________________________________
Child(ren) live(s) with:
Parent's Name:____________________________________________________________________
Parent's Home Phone:______________________Parent's Work Phone:_____________ext._______
Parent's Job Title:__________________________Parent's Occupation:________________________
Parent's needed drop-off time:____________a.m. / p.m.
Parent's needed pick-up time:_____________a.m. / p.m.
Parent's Name:_____________________________Parent's Work Phone:_____________ext.______
Parent's Home Phone:________________________Parent's Work Phone:_____________ext._____
Parent's Job Title:___________________________Parent's Occupation:_______________________
*Only answer the following three questions if you are currently seperating or are seperated:
from your child's parent:
1) Are you currently trying to finalize full custody and or visitation rights?
2) Do you already have full custody of your child(ren)?
3) Is the other parent allowed to pick-up your child(ren) at all?
If your child(ren) is / are accepted when is your needed start date? _______________________________
Do you have an e-mail address where we could reach you:_____________________________________
Additional Children:
Name:___________________________________________Date of Birth:__________________
Name:___________________________________________Date of Birth:__________________
Thank you for submitting the application we will call or e-mail you to schedule an interview as soon as
possible. If you are submitting this application on-site then please allow us a minumum of 48 hours to make
our decision.
Parent / Guardian Signature:_____________________________________________
