Application

Child's Information

Todays Date

Email Address

Child's Name

Date of Birth

Social Security No

Parent Information

Primary Caregiver

Living in home with child
YesNo

Address

Phone Number

Address

Employer

Employers Address

Phone Number

Social Security

Drivers License No

Parent Information

Primary Caregiver

Living in home with child
YesNo

Address

Phone Number

Employer

Employers Address

Phone Number

Social Security

Drivers License

Preferred Hours

Preferred Start Date

AM

PM

Full Day

Preferred Schedule days

Monday

Tuesday

Wednesday

Thursday

Friday

Preferred Program

For Office Use Only

Tuition

First Months Tuition

Lunch

Non-Refundable Registration Fee Paid:

Check

Cash

First Month’s Tuition Paid:

Check

Cash

Group

Teacher

Parent Agreement Form Signed

Enrollment Packet Completed