Phone:
937-498-4566
| Fax:
937-493-4612
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Contact Us
Home
About Us
Our Staff
Board of Directors
Enrollment
Policies & Forms
Resources
News and Events
Photo Gallery
Donate/Payments
Contact Us
Child Information
Name
Email Address
Address
City
Zip Code
Date of Birth
Sex
Male
Female
Date you wish to start child In program
How did you hear about our center?
Referred by:
Is your child currently enrolled in another daycare program?
If so, where?
Does your child currently attend preschool?
Yes
No
Shelby Hills Preschool:
AM
PM
Teacher’s Name:
Whittier Early Childhood Center:
AM
PM
Teacher’s Name:
Other Preschool:
Child’s School District for Kindergarten:
What (if any) special needs does your child have? (Disabilities, Diagnosis, Allergies)
Does your child nap?
Yes
No
Comments re: nap if needed:
Parent or Guardian Information
Mother's Name
Mother's Home Address
Mother's Home Phone
Mother's Email Address
Mother's Employer Name
Mother's Work Phone
Mother's Cell Phone
Can we text Mother's cell phone?
Yes
No
Father's Name
Father's Home Address
Father's Home Phone
Father's Email Address
Father's Employer Name
Father's Work Phone
Father's Cell Phone
Can we text Father's cell phone?
Yes
No
Contact #3
Contact #3 Relationship
Contact #3 Work Phone
Contact #3 Cell Phone
Can we text Contact #3's cell phone?
Yes
No
Weekly Schedule (Please Fill Out Completely)
In Monday
Out Monday
In Tuesday
Out Tuesday
In Wednesday
Out Wednesday
In Thursday
Out Thursday
In Friday
Out Friday
The following forms must be turned in before your child can start in daycare:
Birth Certificate, Immunization Record, Medical Form signed by a physician, Emergency Medical Authorization, Parent Roster Info, $25 Registration fee, Keycard fee if applicable, and first week’s payment.
Parent/Guardian Signature
Date
