Online Application – Children's Place Learning Center

Enrollment Application

Childs Date of Birth/Due Date *

Enrollment Date *

Child's Name *

Child's Nickname

Street Address *

City

State/Province

ZIP / Postal Code

Phone *

Special Visitation/Custody Considerations(N/A if not applicable) *

Who will typically pick-up your child from our care? *

Family Information

Mother's/Legal Guardian Name *

Phone *

Employer's Name

Business Phone

Street Address

City

State/Province

ZIP / Postal Code

Father's/Legal Guardian Name *

Phone *

Employer's Name

Business Phone

Street Address

City

State/Province

ZIP / Postal Code

Siblings

Name

Sex

Birthdate

Name

Sex

Birthdate

Name

Sex

Birthdate

Child's Medical Information/History

Family Doctor

Phone

Family Dentist

Phone

Health Insurance Provider

Policy #

Phone

Does your child have any known allergies, special medications, or other special needs? *

List below any medications your child is receiving, how often, and prescribed by whom(N/A if not applicable):

Medication *

Frequency

Physician

Medication *

Frequency

Physician

Medication

Frequency

Physician

Medication

Frequency

Physician

Background Information

Does your child have experience being cared for outside of the home? *

Yes, in a group settingBy a person other than parents

Explain the care outside of the home

Has your child had any severely upsetting experiences such as divorce of parents, death in the family, frequent or recent moves, etc.

Please list any information about your child which will be helpful in the experience adjusting to a new environment such as eating, sleeping, play, fears, habits, likes, dislikes, etc.

Remarks for special concerns

I hereby agree to cooperate with the facilities regulations. In case emergency medical care is necessary, I hereby give my permission for my child to receive care by the attending physician.

I understand there is a $25 application fee that needs to be submitted with my application, via mail or in person. Once Children's Place has received both the application and application fee your child will be placed on the enrollment list.