Please fill out the form below, and then click the submit button at the bottom of the page.
We thank you for taking the time to contact us, and we look forward to getting back to you very soon.

Child’s Name:
Gender:
Birthday:
Home Phone:
Home Address:
Basic Information:

Mother/Guardian’s


Mother/Guardian’s Name:
E-mail Address:
Employer:
Home Phone:
Cell Phone:
Address:
Business Phone:

Father/Guardian’s


Father/Guardian’s Name:
E-mail Address:
Employer:
Home Phone:
Cell Phone:
Address:
Business Phone:

Child’s First day of care:


Child’s First day of care:

List of the names authorized to pick up your child




It is understood that all persons authorized for pick-up must present Identification before being allowed to take child. She/He will not be allowed to leave the Center with anyone else unless the Center has been previously notified. Children under the age of 13 will not be allowed to pick up your child. Further, the Center retains the right to withhold your child from being picked up by anyone who appears intoxicated, careless or untidy.

Signature of Parent/Guardian:
Date: