Pre-enroll for Daycare

Child's Birthdate *

MM

DD

YYYY

Child's Gender *

Male

Female

Prefer not to answer

Child's Physical Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What program are you registering for? *

Infant Program (0-12 months)

Toddler Program (1-3)

Preschool (3-4)

Pre-K (4-5)

Guardian's Name *

First Name

Last Name

Address

(if different from child's)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Work Phone

(###)

###

####

Cell Phone

(###)

###

####

Does your child have a second guardian? *

If you answer yes, please complete the fields below.

Yes

No

Guardian's Name

First Name

Last Name

Address

(if different from child's)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Work Phone

(###)

###

####

Cell Phone

(###)

###

####

Is your child's immunization record up to date? *

Yes

No

Office Phone *

(###)

###

####

Phone

(###)

###

####

Do you qualify for any of these discounts?

(Proof of documentation will need to be provided at time of enrollment.)

Military

Teacher

NON-REFUNDABLE APPICATION FEE *

You will be directed to a link to pay this fee after submitting this application. Please email us if you need to do a check or direct deposit payment.

I understand that a $175 NON-REFUNDABLE application fee is due with this application, and that this application and payment of this fee do not guarantee enrollment.

Consent for Electronic Signature *

I consent to signing this form electronically.

Date of Application *

MM

DD

YYYY