Enrollment Form

  • Please list 2 people who can be contacted in an emergency if parent(s) cannot be reached:

  • NamePhone NumberRelationship to child 
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    Please list names of people you authorize to take your child from the day care (Children would NOT be allowed to leave with anyone without authorization from parents or guardian)
  • Sibling(s) name and/or others living in the homeBirthday / AgeChild living in home Y/N 
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  • Medical History