Daycare Nursery Admission Form

Daycare Nursery Admission Form
Please complete this form to apply for your child's admission to our daycare nursery.
Child's Full Name
First NameLast Name
Child's Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child's Gender
Other
Home Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Parent/Guardian Full Name
First NameLast Name
Relationship to Child
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email Address
example@example.com
Emergency Contact Name
First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Persons Authorized to Pick Up Child (list names and relationship)
Does your child have any allergies or medical conditions? If yes, please specify.
Has your child been immunized as per recommended schedule?
Should be Empty: