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Date *
Child's Name *
Child's Name
Child's Date of Birth *
Child's Date of Birth
Parent Name *
Parent Name
Address *
Phone *
To meet your child care needs as quickly as possible, we need two (2) additional contact phone numbers.
Phone 1 *
Phone 1
Relation to Child *
Relation to Child
Phone 2
Phone 2
Relation to Child
Relation to Child
Please contact us if any of the above information changes. Your application will stay on file for 6 months unless phone, e-mail or walk in inquiries are performed. Tuition is calculated on a sliding fee base. Fees include: $40 enrollment fee and an annual $30 supply fee (prorated from August)