ENROLLMENT FORM

Child’s Name:

Date of Birth:

Home Address:

Sex:

Primary Language:

Telephone:

Height:

Weight:

Eye Color:

Skin Color:

Identifying Marks:

Allergies/Special Diets:

Parent/Guardian Name:

Relationship to Child:

Home Address:

Email

Bus. Name:

Bus. Address:

Telephone #:

Hours at Work:

Child’s Physician/Clinic:

Telephone #:

Chronic Health Conditions:

Special Limitations or Concerns: