Enrollment Information


Child’s Name (First, Middle, Last) Nickname


Birth date Child’s Age at Entry Date Enrolled Allergies
Parent/Guardian Name

(First, Last)

Home Phone #

Work/Cell Phone #

Home Address

Work Address

Parent/Guardian Name

(First, Last)

Home Phone #

Work/Cell Phone #

Home Address

Work Address

Legal Gaurdian’s Name Relationship to Child Home:




Medical Provider ___________________________________  Phone ______________________


Child’s Dentist   ____________________________________    Phone ____________________


Insurance Provider ______________________________________________________________


Emergency Contacts (other than parent(s)/guardian:

We always try to contact parents first. However, we are required to have emergency contacts OTHER THAN the parents. These people are also authorized to pick up your child from the center. Please list all phone numbers that are appropriate.

Name of Contact Relationship to Child Home:
Name of Contact Relationship to Child Home:


Contract of Care

Monday Tuesday Wednesday Thursday Friday
Infant/Toddler Half Day
Infant/Toddler Full Day
Preschool/ Pre-K Half Day
Preschool/ Pre-K Full Day

* Please note the times and days you plan for your child to attend

* For ease of scheduling, we prefer you not mix and match half and full day spaces.


My Signature gives permission for the following:


  • In an emergency, this facility has my permission to call an ambulance or to take my child to any available physician or hospital at my expense and to obtain medical treatment for my child. In most emergencies, 911 is called and the child is transported to nearest hospital and seen by the doctor on call. (Parents are notified ASAP)
  • My child may be given non-prescribed medication as indicated on the container, including sunscreen, children’s pain reliever, children’s Benadryl, antibacterial first aid cream, and diapering ointment. Syrup of Ipecac may be administered if deemed necessary by the Poison Control operator. (We will contact parents prior to administering non-prescription pain relievers. Prescription medications must be current and require a Medication Authorization) .
  • My child may be taken on field trips or excursions by bus or private vehicle and on neighborhood walking excursions under required supervision.
  • My child may participate in swimming or other water activities under required supervision.
  • My child may be photographed for publicity or news purposes.


Parent/Guardian Signature ____________________________________________Date ______________________

Parent Responsibilities

To help us provide the best care and educational environment for your child, please provide us with the following items:


  • Completed enrollment packet and immunization card
    • (please update us if there are any changes of address, phone #’s, allergies, etc.)
  • Labeled Sunscreen
  • Labeled Water bottle
  • A backpack or bag for your child’s belongings
  • 2 weather appropriate changes of clothes for your child
  • A healthy lunch each day
    • To meet USDA standards, please be sure your child has at least one serving from each food group per day (grain, protein, fruit, vegetable).
    • Please avoid sending any sweets/treats unless it is a special occasion and you are bringing some to share with everyone to celebrate.
    • We will provide a snack in the morning and afternoon as well as a serving of milk with lunch.
      • If your child has any diet restrictions, please let us know, and provide the necessary substitutes (non-dairy, gluten free, etc.)
  • Medications- We will need a Medication Authorization for each medication you would like us to administer, whether is is prescription or over the counter.
  • Billing/Payment
    • On time payment of the 1st of the month and no later than the 10th.
      • $10 fee per late day
      • $25 late pick-up fee
  • School Supplies to share:
    • 1 box of washable Crayola Markers
    • 1 box of washable Crayola Crayons
    • 1 box of erasable Crayola Colored Pencils
    • 1 package of Construction Paper
    • 1 package of white printer paper
    • 1 box of tissues
    • 1 bottle of Elmer’s white school glue
    • 1 package of glue sticks
    • 1 plastic pocket folder for your child to transport important papers/homework

(Please let us know if providing these items is an issue for your family- it is helpful, but not an absolute requirement for attendance. If you can provide more than the requested items, that would help other families in need. Thank you!)


No Child will be released to an adult other than the parent/guardian (or those listed as emergency contacts) without prior parental consent.


My signature here states that I have read and understand these requirements and will comply.


Parent Signature _________________________________________ Date ________________