Childcare Program Insurance Enrollment
Complete this form to enroll your child in the childcare program's insurance coverage.
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Does your child have any existing medical conditions or allergies?
Parent/Guardian Full Name
*
First Name
Last Name
Relationship to Child
*
Parent/Guardian Email Address
*
example@example.com
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Select the Childcare Program
*
Please Select
Full-Time Daycare
Part-Time Daycare
After-School Program
Summer Camp
Other
Select Insurance Plan
*
Basic Coverage
Extended Coverage
Premium Coverage
Insurance Policy Number (if renewing)
Parent/Guardian Signature
*
Submit Enrollment
Submit Enrollment
Should be Empty: