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milestoneslearning
2021-01-13T21:49:32+00:00
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CHILD'S NAME (LAST, FIRST, MIDDLE) (REQUIRED)
*
CHILD'S Date of Birth (REQUIRED)
*
DESIRED DATE OF ENROLLMENT(REQUIRED)
*
MOTHER'S NAME AND ADDRESS
MOTHER'S TELEPHONE AND EMAIL ADDRESS
MOTHER'S EMPLOYER
FATHER'S NAME AND ADDRESS
FATHER'S TELEPHONE AND EMAIL ADDRESS
FATHER'S EMPLOYER
Has your child been in child care before?
Yes
No
Are you also enrolling a sibling?
Yes
No
If so, what is the sibling name and date of birth?
Does your child have any know allergies?
Yes
No
If "Yes" please list
Does your child have any chronic illness or condition?
Yes
No
If "Yes" please list (copy)
PLEASE GIVE ANY INFORMATION CONCERNING YOUR CHILD'S GENERAL HEALTH OR PERSONAL HISTORY THAT WOULD BE HELPFUL IN THEIR EXPERIENCE IN A GROUP SETTING (EXAMPLES FEARS, UNIQUE BEHAVIORS, CHARACTERISTICS, ETC.)
(REQUIRED)
*
Full time (Monday through Friday)
Monday/Wednesday/Friday
Tuesday/Thursday
First Available
TODAY'S DATE (REQUIRED)
*
Phone
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