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ENROLLMENT FORM
Enrollment Date
*
+
Child's Name
*
Birth Date
*
+
Address
*
Mother's Name
*
Phone Number
*
Mother's Work Phone Number
*
Mother's Address
*
Father's Name
*
Phone Number
*
Father's Work Phone Number
*
Father's Address
*
Child Lives With:
*
Both Parents
Mother
Father
Other
Other
Child's Legal Guardians:
*
Both Parents
Mother
Father
Other
Other
Days of Week Attending
*
Hours of Day Attending
*
THE CHILD MAY BE RELEASED TO THE PERSON(s) SIGNING THIS AGREEMENT OR TO THE FOLLOWING:
Name
Relationship
Phone Number
Name
Relationship
Phone Number
PERSONS TO CONTACT IN CASE OF AN EMERGENCY WHEN PARENTS CANNOT BE REACHED:
1. Name
*
Phone Number
*
Address
*
2. Name
*
Phone Number
*
Address
*