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Child Application Form
Little Journeys Early Learning Child Care Center
Child Information
Child's Full Name
*
Child's Nickname
(if applicable)
Street Address
City
State
Zip Code
Child's Schedule
Are you enrolling for:
5 days: M-F
3 days: M/W/F
2 days: Tu/Th
Arrival and Departure Times:
Mon
Tues
Wed
Thurs
Fri
Arrival
Departure
Date of Birth
Gender
Male
Female
Primary Language
Medical Information
Eye Color
Hair Color
Height
Weight
Identifying Marks
Does your child have any allergies?
Yes
No
Explain:
Is your child taking any medications?
Yes
No
Explain:
Does your child require any special care?
Yes
No
Explain:
How did you hear about us?
Friend/Family
Online/Google
Social Media
Word of Mouth
Other:
Parent/Guardian Information – Contact #1
Name
*
Relationship
Email
*
Primary Phone
*
Secondary Phone
Same address as child
Street Address
City
State
Zip Code
Employer Information
Employer Name
Occupation
Business Phone
Business Email
Business Address
City
State
Zip Code
Parent/Guardian Information – Contact #2
Name
Relationship
Email
Primary Phone
Secondary Phone
Same address as child
Street Address
City
State
Zip Code
Employer Information
Employer Name
Occupation
Business Phone
Business Email
Business Address
City
State
Zip Code
