Child Care Registration Form

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Child's Name

(1)
Date of Birth
Classroom

(2)
Date of Birth
Classroom

Mother's Name

Home Address

City/Zip

Employed at

Employer Address

Work Phone

Cell Phone

Driver's License #

Email Address

Fathers's Name

Home Address

City/Zip

Employed at

Employer Address

Work Phone

Cell Phone

Driver's License #

Email Address

I understand that my $50.00 waiting list fee and/or $100.00 registration fee is nonrefundable. If after the third phone call I do not accept the space available, I will automatically forfeit my deposit or registration.