Enrollment Form - Googols Of Learning Child Development Center

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Googols of Learning Child Development Center

Enrollment Form

Child’s Full Name: _________________________________________Nickname if any: __________________

M______F______

Date of Birth: _____________________

Home Address: ________________________________________________ Home Phone: _________________

Mother/Guardian’s Name: ___________________________________________ Cell Phone #______________

Mother/Guardian’s work: ___________________________________________ Work number: _____________

Father/Guardian’s Name: ____________________________________________ Cell Phone # _____________

Father/Guardian’s work: ____________________________________________ Work number: ____________

Mother/Father/Guardian email:________________________________________

Mother’s Driver’s License #_____________________ Father’s Driver’s License #_______________________

Yes

Are parents Single, Married, Divorced, Separated? Do both parents live in the home?_____________________

If you are divorced please describe the custody and visitation agreement for your child(ren). You may attach

another sheet of paper if needed or a copy of court documents.

__________________________________________________________________________________________

______________________________________________________________________________

Child’s Physician: ________________________ Phone and address: _________________________________

Child’s Dentist ___________________________ Phone and address: ________________________________

People that Googols of Learning can contact if you cannot be reached in an emergency: