Date of Enrollment: _________________________________________________

Child's Name: ________________________________________________________

Does your child go by any other name? Yes Please list: ______________________
No

Name of Parent/Guardian: _______________________________________________

Date of Birth: _______________________________

Address: _______________________________________________________________

City: _______________________________________

Do you and your child have the same address? YES

NO If no, Please list child's addres

Name of Family Membes:

Phone:
Home _______________________________
Work ________________________________
Cell _______________________________

Email Address: _______________________________________________________________

Place of Employment _______________________________________________________________

Employer Address _______________________________________________________________

City: _______________________________

Work Schedule: Monday Tuesday Wedneday Thursday

Emergency Contact 1
Name : _______________________________________________
Cell _______________________________
Relationship to child ____________________________________
Authorized for Pickup? YES
NO

Emergency Contact 2
Name: _______________________________________________
Cell: _______________________________________________
Relationship to Child: ____________________________________
Authorized for Pickup? YES
NO

Emergency Contact 3
Name: _______________________________________________
Cell: _______________________________________________
Relationship to Child: ___________________________________
Authorized for Pickup? YES
NO
 Little Learners Childcare Learning Center
Enrollment Forms

________________________ Date of Birth: _____________________________

_____________________________________________________________

_____________________________________________________________

______________________________________________________

_______________ State: _____________ Zipcode: __________________

no, Please list child's address: ________________________________________________________________________

City: ____________________________ States:

_________________________________

__________________________________
_______________________________________________________

State: _____________ Zipcode _____________________

Friday

________________________________________________
_________________________________________
_____________________________ _____________________

_________________________________________________
__________________________________________________
___________________________________________________

__________________________________________________
___________________________________________________
____________________________________________________
________________

____________________________

_________ Zipcode: __________

___________________
Name of Doctor Office: _____________________________________________________________

Address: _____________________________________________________________

City: ________________________________

Phone:
Office ________________________________

Fax: ________________________________

Name of Preferred Hospital: __________________________________________________

Name of Physician: ______________________________________________________

Date of Last Physical: _____________________

Does your child have any allergies? YES

NO
If yes, Please list name of medication and dosage

Has your child had a seizure? YES

NO
If yes, When was the last episode?
 Medical Form

________________________________________

______________________________________

State: ___________ Zipcode : __________

_______________________________________________________________________

___________________

ication and dosage

____________________