St. Paul's Child Care Center - Application Form and Enrollment Information

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Application for Enrollment
St. Paul's Child Care

Child's Name: Birth Date (Or Due Date):

Name/Nickname Preferred: Child's Gender: Male Female

Name of Parents/Guardians

Mailing Address:

Telephone (Home & Cell):

E-Mail Address :

Mother's/Father's Name & Address (if different):
Telephone:

Father's Occupation: Telephone:

Mother's Occupation: Telephone:

Business Name and Address:

Pediatrician's Name: Telephone:

Emergency Contact: Telephone:

REQUEST FOR ADMISSION
Application Date: Enrollment Date:

**REQUEST FOR ADMISSION**
	Application Date: Enrollment Date:

PROGRAM REQUESTED

Infant Mobile Infant Toddler Preschool

**PROGRAM REQUESTED**
	Infant Mobile Infant Toddler Preschool

Signature:__________________________________________ Date:_________________

A nonrefundable fee of $100 is required with this application. This fee does not guarantee a spot.
Please print a copy of this document for your own records.

© 2006 St Paul's Evangelical Lutheran Church
(914) 939-3079 Child Care Center
(914) 939-8170 Church Office
(914) 939-8283 FAX

Last Updated 01/29/07