Interested in your child going here? Fill out some info and we will be in touch shortly! We can't wait to hear from you! Child's Name * First Name Last Name Birthday * MM DD YYYY Child's Gender Female Male Do you have a second/ third child you would like to submit applications for well * Yes No If yes, please include sibling(s)'s name(s) Parents/Guardians are: * Please select all that apply Married/Together Mother Remarried Father Remarried Separated Divorced The Child(ren) lives with Please list the names and relationship of the child's immediate family members, and ages for siblings, as applicable [e.g. Derek (dad), Mary (mom), Sarah (sister)] I am interested in enrolling my child(ren)... * As soon as possible Beginning in the summer 2024 Beginning in August 2024 Beginning in the middle of the 2024-2025 school year I am interested in my child(ren) beginning during the following session: 2024 summer camp 2024-2025 I am interested in enrolling my child(ren) in the following program * Full Day enrollment After School only Desired Start Date * MM DD YYYY I am interested in enrolling my child(ren) in the following extended day program(s) * Please select all that apply. Early Stay (Arrival any time between 6:30am-8:00am) Late Stay (Pick up any time between 3:00pm-5:30) I am not interested in either Early or Late Stay. How did you hear about us? Parent/Guardian 1 Families with parents/guardians living separately with shared custody are welcome (but not required) to both independently complete an Application for enrollment. Relation to Child * Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Workplace/Business * Required by state licensing (can write in stay-at-home-parent, or other). Workplace/Business Address * Required by state licensing (please write in full street address). Mobile Number * (###) ### #### Home Number (###) ### #### Work Number (###) ### #### Parent/Guardian 1 Email * Parent/Guardian 2 Please include all relevant information below if more than one parent/guardian has custodial rights. Relation to Child Name First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Workplace/Business Required by state licensing (can write in stay-at-home-parent, or other). Workplace/Business Address Required by state licensing (please write in full street address). Mobile Number (###) ### #### Home Number (###) ### #### Work Number (###) ### #### Parent/Guardian 2 Email Background information Previous Schools/Childcare Experience * Please list every school/childcare that your child has attended. Special Needs * Does your child have any special needs (developmental, medical, or psychological)? Has your child received any testing or evaluations that may impact their experience at Little Blessings? Thank you!
