423 Park Avenue Suite 207 Huntington, ny 11743 631. 385. 0944 Fax 631. 470. 8081

Дата канвертавання20.04.2016
Памер8.81 Kb.
Village Green Day Care Center, Inc. Operated By:

Calling All Kids, Too, Inc.

423 Park Avenue Suite 207 Huntington, NY 11743 631.385.0944 Fax 631.470.8081

Serving: Town of Huntington and Huntington Township Chamber Foundation


Please fill out this application completely. Accurate information is necessary so that we may best serve your child’s needs. It is your responsibility to notify us of any changes in employment or residence. A non-refundable $100.00 registration fee must be submitted with this application.

Family Name___________________ Child’s Name___________________

Birth date_____________________ Start Date__________________
Mother’s Name__________________ Father’s Name__________________
City ___________ State_______ Zip ________Home Phone_____________
Child’s Legal Guardian_______________________________________
Days of Care Needed__________________ Hours Needed__________
Mother’s Employer_________________________________________
Position________________________ Work #___________________
Work Hours __________to________ Cell # ____________________
Mother’s Email ___________________________________________
Father’s Employer_________________________________________
Position_______________________ Work #____________________
Work Hours _________to _________ Cell # _____________________
Father’s Email _____________________________________________
Has your child previously attended a child care center? _____________
Where? _______________________ How long? ___________________
Age of child when mother returned to work _______________________
Family Doctor _____________________________________________
Address _________________________________________________
Phone # ________________________

I agree to the enrollment of the child listed above, and have been advised of the fees and policies. I consent for my child to take part in field trips or excursions away from the facility under proper supervision. I agree that in case of accident or injury, emergency medical care may be given by the Physician, Nurse and/or Hospital chosen by the facility, in the event I or person(s) designated as emergency contacts cannot be reached.

Parent’s Signature___________________________________________
Please provide us with any special instructions below.

Thank You.

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