Enrollment Form

Download other required consent/health forms here.

Student Information

Child's First Name:

Child's Middle Name:

Child's Last Name:

Address:

City:

State: Zip Code:

Birthdate:

Gender:

Home Phone:

Ethnicity (select one) :

Hispanic or Latino
Non Hispanic or Latino

Race (select one) :

Asian
Black or African American
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
White

List other family members in the home:

Name:		Age:
Name:		Age:
Name:		Age:
Name:		Age:

Indicate the days and times your child will be in the center:

Monday:
Tuesday:
Wednesday:
Thursday:
Friday:

Anticipated meal participation:

am snack

lunch

pm snack

Parent/Guardian Information

Mother's Information

Mother's Name:

(if different than child's)

Address:

City:

State: Zip Code:

Home Phone:

Cell Phone:

Employer:

Work Phone:

Father's Information

Father's Name:

(if different than child's)

Address:

City:

State: Zip Code:

Home Phone:

Cell Phone:

Employer:

Work Phone:

If there is a seperation, divorce or custody problem of which
we should be aware, please explain:

Authorization to Pick Up

Persons authorized to pick up your child:

Name	Relationship to Child	Phone

Note: Only authorized persons will be allowed to pick up your child unless prior arrangements have been made. Identification will be required.

How did you find out about us?

If other, specify

Parent/Guardian Name:

Date:

October 22, 2017

Your email:

Note: By submitting this form you are certifying that you are the Parent/Guardian of the child (listed above) and all the information submitted is correct.