Child’s Full Name

Child’s Date of Birth

Gender
MaleFemale

Home Address

Allergies or Medical Conditions

Child’s Age Group
Infant (6 Months to 18 Months)Toddler (18 Months to 30 Months)Preschoolers (2.5 to 4 years)

Parent/Guardian Information
Parent/Guardian Full Name

Phone Number

Email Address

Address (if different from child)

Emergency Contact (if different from parent)

Enrollment Details

Start Date

Days of Attendance (e.g., Monday–Friday or selected days)
MondayTuesdayWednesdayThursdayFridaySaturday

Hours of Care (full-day or half-day)
Full DayHalf Day

Authorized Pickup Persons