Name of Child *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Name of Child

First Name

Last Name

Child DOB

MM

DD

YYYY

Guardian 1 *

First Name

Last Name

Guardian 1 *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Guardian 1 DOB *

MM

DD

YYYY

Guardian 1 Cell Phone *

(###)

###

####

Guardian 1 Employer Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Guardian Work Phone *

(###)

###

####

Guardian 2

First Name

Last Name

Guardian 2 (If different from 1)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Guardian 2 DOB

MM

DD

YYYY

Guardian 2 Cell

(###)

###

####

Guardian 2 Employer Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Guardian 2 Work Phone

(###)

###

####

What days of the week is your child currently attending school in person? *

Monday

Tuesday

Wednesday

Thursday

Friday

None

What schedule program will you be using? *

Full Time-$130/week

3 days-$90/week

2 days-$60/week

Please Choose your pay Option *

All payments are non-refundable. 2 week notice for program drop-out to allow us to schedule proper staffing.

Monthly-Must be made in full by the 5th of each month. Non Refundable. $25 late fee

Bi-Weekly-Choose set payment dates twice a month. Must be paid in full by Friday at 5pm the week prior to care

Weekly- Must be paid in full by Friday at 5pm the week prior to care

Requested Start Date *

MM

DD

YYYY