Daycare Enrollment Form

Date of App

Child’s Name

Date of Birth

 Male Female

Address

City, State, Zip

Mother’s Name

Home Telephone

Mother’s Place of Employment

Address

Work Phone

Father’s Name

Place of Employment

Address

Work Phone

Please give the day and hours day care service is needed

Emergency Contact

Name

Address

Phone

Relationship

Child’s Physician

Phone

Disease History Dates: A copy of the child’s current immunization is required before your child can be enrolled at New Pisgah Day Care Center:

Measles Chicken Pox Mumps Whooping Cough German Measles Ear Infection 

Allergies

( Please list all food and medical alerts)

Date of Enrollment

Date Discharged

Your Name (required)

Your Email (required)