Registration Form
Child Name:
*
Child Date of Birth:
*
Desired Enrollment Date:
*
Street Address:
*
City
*
State
*
Postal Code
*
Parent’s Names:
*
Cell Phone Number:
*
Additional Phone Number:
Gender:
*
Male
Female
Potty Trained?
*
Yes
No
Are your child’s immunization shots up to date?
*
Yes
No
Person to contact in case of emergency:
*
Emergency Telephone Number:
*
Has your child attended another licensed childcare facility before?
*
Does your child have medical conditions or allergies?
*
Submit
$125 - Registration Fee
[email protected]
5664 Silver Hill Rd, District Heights, MD 20747
6:30am - 6:30pm (Monday - Friday)
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