Before and After school Program – Little Scholars II Daycare Center

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Child's Full Name

Child's Date of Birth

Child's Age

Gender

Preferred Start Date

Select Program

Parent Full Name

Relationship to Child

Phone Number

Email Address

Home Address

City

State

Zip Code

Emergency Contact Name

Emergency Contact Number

Relationship to Child

Desired Schedule

Estimated Drop-Off Time

Estimated Pick-Up Time

Allergies

Medical Conditions

Dietary Restrictions

Special Needs or Additional Information

Authorized Pickup Person Full Name

Contact Number

Relationship to Child

I certify that the information provided is accurate.

I agree to be contacted by Little Scholars II regarding enrollment.