School Age Child Care Supplemental Enrollment Form

Completion of this agreement is required for enrollment. This form will enable us to better understand your child and meet his/her needs. Much of the information requested is necessary to comply with state child care licensing regulations.

Child’s Information

Child’s first name

Child’s middle name

Child’s last name

Child’s nickname

Age

Sex

Child’s primary language

Parent/guardian/sponsor primary language

Child’s home address

Street Address Address Line 2 City State ZIP Code

Does your child attend school?

Yes

School name

Grade

Untitled

School phone

School address

Street Address Address Line 2 City State ZIP Code

Drop off time

Pick up time

Child will be attending:

Summer Care

Afternoon Care