This form is divided into sections and all are "minimized" (closed) by default. To expand each section, just click on the section name. All mandatory items are marked with a red ( * ) asterisk.

BY SUBMITTING THIS ONLINE APPLICATION YOU AGREE TO THE FOLLOWING:
- A late fee will be charged for late pickups (see Parent Handbook for more information)
- Agree to pay in advance, each week's tuition
- Are aware that a $10.00 late fee will be charged for payments received after Tuesday of the paid week
- Agree to pay a registration fee at the time of enrollment to be renewed each September
- The registration and tuition fees are NON-REFUNDABLE
- A TWO WEEK NOTICE IS REQUIRED before your child leaves the center
- You have received and have read the Parent Handbook (found here), which contains additional policies and procedures and you agree with ALL policies and procedures.

Your Name: *

The name of the person submitting this application

Your Email Address: *

The email address of the person submitting this online application.

Requested Date of Enrollment: *

MonthJanFebMarAprMayJunJulAugSepOctNovDec

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Year200920102011201220132014201520162017

What is the anticipated date that you would like to enroll your child?

Child's Information

Please fill in only the child's information in this section.

Name: *

Nickname:

Birthdate: *

MonthJanFebMarAprMayJunJulAugSepOctNovDec

Day12345678910111213141516171819202122232425262728293031

Year200020012002200320042005200620072008200920102011201220132014201520162017201820192020

Current Age: *

Gender: *

Male

Female

City:

Home Address:

State:

Zip Code:

Home Phone:

Is Child Potty Trained?:

Yes

No

Does your child have any special fears or problems?:

Has your child been cared for by someone other than parents?:

Yes

No

If yes, please detail below.

If yes, whom?:

Church Information

Local Church Name:

Do you have a local church home?

Actively Attend:

Yes

No

Father/Gaurdian Information

Name: *

Home Address: *

City: *

State: *

Employment: *

Home Phone: *

Mobile Phone: *

Work Phone: *

Work Hours: *

Mother/Gaurdian Information

Name: *

Home Address: *

City: *

State: *

Employment: *

Home Phone: *

Mobile Phone: *

Work Phone: *

Work Hours: *

Parent Information

Marital Status: *

Married

Single

Divorced

Custody (if applicable):

mother

father

other (see other section below)

Other:

Non-Custodial Parent Pickup Status:

Yes

No

May the parent who does not have custody of child pick the child up?

NOTE: If YES, include his/her name in the "Release Section" of this form.
If NO, documentation from the court is REQUIRED! (no exceptions!)

Release Section

THE CHILD WILL BE RELEASED ONLY TO THE PEOPLE ON THIS APPLICATION AND THE FOLLOWING PERSONS IN THIS SECTION

Release Person #1

Name:

Address:

Work Phone:

Home Phone:

Mobile Phone:

Release Person #2

Name:

Address:

Work Phone:

Home Phone:

Mobile Phone:

Release Person #3

Name:

Address:

Work Phone:

Home Phone:

Mobile Phone:

Emergency Information

Physician's Name:

Physician's Address:

Physician's Phone Number:

Child's Known Allergies: *

Hospital Preference: *

Emergency Contact #1

This must a NON-parent emergency contact and must be within 30 minute drive of daycare facility

Name:

Address:

Work Phone:

Home Phone:

Mobile Phone:

Emergency Contact #2

This must a NON-parent emergency contact and must be within 30 minute drive of daycare facility

Name:

Address:

Work Phone:

Home Phone:

Mobile Phone:

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