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Child's Full Name

Date of Birth

Gender

Parent/Guardian Full Name

Cell Phone #

Email Address

Address

City

State

Zip Code

Does your child have any special needs, behavioral, medical, physical conditions of which we should be aware?

Yes

Is there a custody order in place? (a copy must be provided)

Yes

Parents are asked to meet with Director prior to enrollment to ensure this program is a good fit for their child. Please explain Special Needs:

Name of Local School (Penny Packer, Rowan, Prince Hall, etc.)

Health Assessment Form

I understand a completed Health Assessment form must be on file prior to admittance.

Parent/Guardian Signature

Type full name as signature for online application.

Today's Date

2020-2021 Child Care for Virtual Learners Application