Child Enrollment and Health Information
Which Center are you applying for

Childs Name                       
firstmiddle last   

Date of Birth
//month/date/year       
 

 Address

City                                  State      Zip
     

Home Phone
()-
 
Parent/Guardian Information
Parent/Guardian Name                       
first last   

Relationship To Child

 
Address

City                                  State      Zip
     
Home Phone
()-
 
Work/School Name

Work/School Address

City                                  State      Zip
     
Work/School Phone
()- ext
 
Parent/Guardian Name                       
first last   

Relationship To Child

 
Address

City                                  State      Zip
     
Home Phone
()-
 
Work/School Name

Work/School Address

City                                  State      Zip
     
Work/School Phone
()- ext
 
 
Attendance Schedule 
Monday Tuesday Wednesday Thursday Friday
Hours: