Childcare Age Group Form
Please complete the following to help us place your child in the appropriate age group and meet their care needs.
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
Child's Gender
Female
Male
Non-binary
Prefer not to say
Other
Parent or Guardian Name
*
First Name
Last Name
Parent or Guardian Email
*
example@example.com
Primary Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Age Group/Class
*
Please Select
Infant (0-18 months)
Toddler (18 months - 3 years)
Preschool (3-5 years)
Pre-K/Kindergarten (5-6 years)
Other
Days of Attendance Requested
*
Monday
Tuesday
Wednesday
Thursday
Friday
Other / Flexible
Does your child have any allergies or special needs?
Emergency Contact Name & Phone
*
Additional Notes or Requests
Submit Enrollment
Should be Empty: