Pre-Registation Form

Child's Information

Child's Full Name:

Date of Birth: MM/DD/YYYY

Gender: (required) Male Female Prefer not to answer

Is child Potty Trained? (required) Yes No

Parent/Guardian Information

Parent/Guardian's Name:

Street Address:

City, State, Zip:

Phone Number:

Email Address: (If none, enter n/a)

The following questions will help to determine which of our high-quality programs will best serve your family’s needs.

Marital Status: (required) Single Married Divorced Widow/er Separated

Child lives with: (check all that apply) (required) Both Parents Mother Father Joint Custody Step Parent Grandparent Foster Care Legal Guardian Other

Number of Adults living in household:

Number of Children living in household:

Names and ages of children in household/school each child attends: (If none, enter n/a) Please include the names and ages of all children in the household.

Gross Annual Income (previous year)

Income Source: (required) Working Child Support Supplemental Security Income (SSI) Other

Will your child need Before/After School Latchkey services? (required) Yes No

Is there any additional information you can share about your child/family? (Check all that apply)

Is there any additional Information that you can share about your child/family? (check all that apply) (required) Abuse/Neglect Challenging Behavior Disability/Developmental Delay English as a Second Language Environmental Risk Health Condition, including Allergies Hearing Individualized Education Program (IEP) Orthopedic Speech/Language Vision Other

Explain any concerns checked or list Medical Conditions/Allergies: (If none, enter n/a)

Pre-Registration Form