Daycare Enrollment Application | Faith Unity Fellowship Ministry

Enrollment Application

We’re excited that you are considering [Daycare Name] for your child’s care and early learning journey. To ensure a safe, nurturing, and organized experience for every family, we require all parents/guardians to complete the registration process. The application will gather important information about your child, family contacts, medical needs, and permissions. Please take a few minutes to complete the form thoroughly—this helps us provide the best possible care and ensures we are prepared in case of an emergency.

Application Date (Required)

Child's First Name (Required)

Child's Last Name (Required)

Home Address (Required)

Child Lives With (Required)

If selected "Other", please provide the name and the child's relationship to the person. (i.e. Grandparent)

Requested Start Date (Required)

Days of Care (Required)

Monday

Tuesday

Wednesday

Thursday

Friday

Approximate times of care (Required)

Please provide full day hours (i.e. 8 AM - 4 PM)

Parent/Guardian Information

Primary Guardian Full Name & Relationship

Primary Guardian Address

Primary Guardian Contact Number

Primary Guardian Work Contact Number

Can you be contacted at work?

Primary Guardian Email Address

Secondary Guardian Full Name & Relationship

Secondary Guardian Address

Secondary Guardian Contact Number

Secondary Guardian Work Contact Number

Can you be contacted at work?

Secondary Guardian Email Address

Tuition

Person responsible for tuition payments? (Required)

Are you on a subsidy program? If yes, you will need to verify by providing a copy of the voucher. (Required)

Authorized Personnel

Your child’s safety is our top priority. Please list all individuals authorized to pick up your child. Once a person is listed below, we may release your child to them without additional notes or calls. If someone not listed will be picking up your child, a parent’s written note or phone call is required.

Are both parents authorized to pick up the child? (Required)

If "No", is there a current legal custody or protective order in place? If so, you will need to verify by providing documentation. (Required)

Authorized Pick Up Person #1: First and Last Name (Required)

Authorized Pick Up Person #1: Relationship (Required)

Authorized Pick Up Person #1: Contact Number (Required)

Authorized Pick Up Person #2: First and Last Name (Required)

Authorized Pick Up Person #2: Relationship (Required)

Authorized Pick Up Person #2: Contact Number (Required)

Authorized Pick Up Person #3: First and Last Name (Required)

Authorized Pick Up Person #3: Relationship (Required)

Authorized Pick Up Person #3: Contact Number (Required)

Emergency Contact Information

Please list at least one emergency contacts who can be reached if we are unable to contact a parent or guardian. Emergency contacts should be local, available during daycare hours, and authorized to pick up your child if needed. Be sure to provide current phone numbers and addresses so we can reach them quickly in case of an emergency.

Emergency Contact #1: First and Last Name (Required)

Emergency Contact #1: Primary Contact Number (Required)

Emergency Contact #1: Work or Secondary Contact Number

Emergency Contact #1: Address (Required)

Emergency Contact #2: First and Last Name

Emergency Contact #2: Primary Contact Number

Emergency Contact #2: Work or Secondary Contact Number

Emergency Contact #2: Address

Emergency Contact #3: First and Last Name

Emergency Contact #3: Primary Contact Number

Emergency Contact #3: Work or Secondary Contact Number

Emergency Contact #3: Address

Child's Physician or Source of Health Care

Physician Contact Number

Consent and Acknowledgement of Registration Information

Participation in Activities - I give permission for my child to participate in all daily activities, classroom projects, outdoor play, and special events organized by Little Lights Early Learning Center. I understand that all activities are supervised.

Authorization of Release - I authorize Little Lights Early Learning Center to release my child only to the parent(s)/guardian(s) listed on this form or to the individuals I have designated as authorized pick-up persons. I understand that I must notify the

Medical Emergency - In the event of a minor injury or illness, I authorize the staff of Little Lights Early Learning Center to provide basic first aid care to my child, including cleaning and bandaging minor wounds. I understand that I will be contacted im

Emergency Authorization - In the event of a serious accident or medical emergency, I authorize the staff of Little Lights Early Learning Center to seek emergency medical treatment for my child. This may include calling emergency medical services (EMS) and

Acknowledgment of Accuracy - I confirm that all information I have provided in this form is accurate and complete to the best of my knowledge. I agree to update Little Lights Early Learning Center immediately if there are any changes to my child’s health,

Parent Signature (Required)

Date (Required)

Solve 5 + 9 = ?

Faith Unity Fellowship Ministry

116 Liberty Ln Chestertown, MD 21620

443-282-0033

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