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ENROLL TODAY
Childs First & Last Name
Childs prefered nickname
Birthday
Month
Day
Year
Gender
Female
Male
Prefer not to say
Address
Grade in School if applicable:
Pediatrician's Name & Telephone Number
Allergies
Special Needs/ Considerations of Child
Name of Person Enrolling Child
Relationship to child
Phone
Okay to Text
Yes
No
Email
Emergency Contact *Name, Relationship, Phone #*
Emergency Contact *Name, Relationship, Phone #*
Name of persons (Other than parent/guardian) Allowed to pick up child: *Relationship, Phone Number*
Desired Schedule:
Desired Days and Hours of Care
Date you would like services to begin?
How do you plan on paying for childcare?
WDI/DSS Program
Cash
Credit Card
Cash App./ Venmo etc.
Submit
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