Application FormTo apply for enrollment, please submit this information in the fields below and submit a non-refundable enrollment fee of $100. PARENT OR GUARDIAN #1 INFORMATION Name * First Name Last Name Phone * (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Birthdate * MM DD YYYY Employer * Work Phone * (###) ### #### PARENT OR GUARDIAN #2 INFORMATION Name First Name Last Name Phone (###) ### #### Email Address Address 1 Address 2 City State/Province Zip/Postal Code Country Birthdate MM DD YYYY Employer Work Phone (###) ### #### CHILD'S INFORMATION Name * First Name Last Name Nickname Birthdate * MM DD YYYY Gender * Male Female Any medical or dietary information we should know about: GENERAL INFORMATION Days of the week you need care (check all that apply): * Mondays, 9:00-11:30 am Tuesdays, 9:00-11:30 am Wednesdays, 9:00-11:30 am Thursdays, 9:00-11:30 am Fridays, 9:00-11:30 am Mondays, 12:30-3:00 pm Tuesdays, 12:30-3:00 pm Wednesdays, 12:30-3:00 pm Thursdays, 12:30-3:00 pm Fridays, 12:30-3:00 pm Relationship status of the child's biological parents * Single Married Separated Divorced Widowed If someone other than the child’s biological parents are the guardian(s), please explain the situation: Other members of the home (siblings, grandparents, step-siblings, etc) and their ages: * Name of church where family attends (if any): If both parents are employed, who primarily stays with the child? * List any group activities in which your child has participated: Thank you for submitting your application!
