Child Enrollment and Emergency Information

Child Information

Child's last name *

First name *

Street address *

City *

State *

ZIP code *

Phone

Date of birth *

Arrival time

Departure time

Gender * Male Female Other

Program selection * Full-Time, Meal Included Part-Time, Meal Included

Mother / Guardian

Last name *

First name *

Initial

Home address

City

State

ZIP code

Home phone

Cell phone

Email

Place of employment

Work phone

Work hours

Driver's license number

Father / Guardian

Last name *

First name *

Initial

Home address

City

State

ZIP code

Home phone

Cell phone

Email

Place of employment

Work phone

Work hours

Driver's license number

Household and Custody

Primary residence * Mom Dad Both Guardian

Marital status Married Single Divorced

If divorced, who has legal custody?

May non-custodial parent pick up? Yes No

Authorized Pickup Contacts

Add every person authorized to pick up the child.

Authorized contact 1

Full name *

Relationship *

Address

Phone

Cell phone

Emergency Contacts

Each emergency contact must also be authorized for pickup.

Emergency contact 1

Full name *

Relationship *

Address

Phone

Cell phone

Health Care Information

Child's physician *

Phone *

Physician address

Hospital preference