Student Enrollment Form

    Child’s Name

    Last:

    First:

    Alias:

    Age:

    Birthday:

    Sex:

    Enrollment Date:

    Mother:
    Legal custodian?
    yesno

    Name:

    SS:

    DL:

    Address:

    Home Phone:

    City:

    Zip Code:

    Employment:

    Phone:

    Email:

    Father:
    Legal custodian?
    yesno

    Name:

    SS:

    DL:

    Address:

    Home Phone:

    City:

    Zip Code:

    Employment:

    Phone:

    Email:

    Child’s Physician:

    Phone:

    Other people authorized to remove your child from the center or who may be contacted in case of illness, accident or emergency if the parents can not be reached:

    Name:

    Phone:

    Address:

    Relationship:

    Name:

    Phone:

    Address:

    Relationship:

    Name:

    Phone:

    Address:

    Relationship:

    Primary Hours of Care:

    Special instructions regarding eating habits, toileting, or areas of concern and allergies.:

    Comments: