Child Enrollment Information Request

DATE *

Childs Information

Childs Full Legal Name *

Name by which the child is most often called *

Date of Birth *

Home Phone Number *

Is a custody order in place for this child? *

Yes

No

Home Address *

Home Address

City

State/Province

Zip/Postal

Country

Duration Needed *

Full Day (over 5 hours)

Part Time (under 5 hours)

Referred by: *

Previous Child Care Centers Attended *

Mothers Information

Mothers Name

Mothers Cell

Mothers Email Address

Mothers Workplace

Mothers Work Number

Mothers Address

City

State/Province

Zip/Postal

Country

Fathers Information

Fathers Name

Fathers Cell

Fathers Email Address

Fathers Workplace

Fathers Work Number

Fathers Address

City

State/Province

Zip/Postal

Country

Relationship Status

Allergies *

Form of Payment *

Private Pay

CCCAP

Mothers Signature *

Fathers Signature

*

Child Enrollment Information Request | We Kare-A-Lot

Childs Information

Mothers Information

Fathers Information