CHILD ENROLLMENT FORM

Date of Application: _______________ Date of Enrollment: ______________ Last Day of Enrollment:_________

Childs Name: __________________________________________

Childs SSN:

Childs Date of Birth: ____________________

Gender

Ethnicity:

Childs Address: ________________________________City: __________________________Zip Code:__________

Mothers Name: ____________________________________ Address:_____________________________________

City: _______________________Zip Code:_________ e-mail address:______________________________________
Home Telephone #: (_____)______________________________ Cell #: (_____)______________________
Mothers Employer: _____________________________________Work #: (____)__________________

Mothers Employer Address: _______________________ City: __________________________Zip Code:_________

Fathers Name: ________________________________ Address: _______________________________

City: ________________________Zip Code:_________ e-mail address: ___________________________________

Home Telephone #: (_____)__________________________

Cell #: (____)_______________________

Fathers Employer: _______________________________________ Work #: (____)___________________

Fathers Employer Address: _______________________ City: __________________________Zip Code:_________

Parents Marital Status:

Married

Separated

Divorced

Child lives with:

If Parents are divorced, who has legal custody:
May the non-custodial parent pick up the child:

Is the child currently in childcare:

Sitter

Daycare

Family Member

Other

Single

Widowed

We are open Monday-Friday from 7:30am-5:30pm and offer two options for care:
Full-time (all day)

or

After school (from 3pm-5pm)

Weekly Care Schedule: (please indicate the childs hours in care for each day)
Monday:

_________________(am / pm) to _________________(am / pm)

Tuesday:

_________________(am / pm) to _________________(am / pm)

Wednesday:

_________________(am / pm) to _________________(am / pm)

Thursday:

_________________(am / pm) to _________________(am / pm)

Friday:

_________________(am / pm) to _________________(am / pm)

If registering for after school care, will your child be attending full time during the summer:

Yes

No

Persons to Call in an Emergency or Release Child to (if parent(s) cannot be reached)

Name: _______________________________________ Address: ______________________________________
Phone #: (____)________________ Phone #: (____)________________ Relationship: _________________

Name: _______________________________________ Address: ______________________________________

Phone #: (____)________________ Phone #: (____)________________ Relationship: _________________

Name: _______________________________________ Address: ______________________________________

Phone #: (____)________________ Phone #: (____)________________ Relationship: _________________

Additional persons child may be released to:

Name: _____________________________

Address: ______________________________________________

Phone #: (____)________________ Phone #: (____)________________ Relationship: _________________

Name: _____________________________

Address: ______________________________________________

Phone #: (____)________________ Phone #: (____)________________ Relationship: _________________

Name: _____________________________

Address: ______________________________________________

Phone #: (____)________________ Phone #: (____)________________ Relationship: _________________

Signature of Parent or Guardian _________________________________________ Date: _____________________