Atlanta Child Care | Atlanta Preschool

Enrollment Form

*All fields are required for us to better assist you.

Name:	Email:
Entrance Date:	Withdrawal Date:
Child's Name:	Sex:	Age:	DOB:
Home Address			Home Phone
Father's Name/Home Address/Telephone Number, If different from child's
Place of Employment/Address of Employment/Business Number
Mother's Name/Home Address/Telephone Number, If different from child's
Place of Employment/Address of Employment/Business Number
Child's Living Arragement: Both Parents Mother Father Other
Child's Guardian(s): Both Parents Mother Father Other
The child may be released to the person(s) signing this agreement or to the following: Name & Address:
1: 2: 3:
Persons to contact in case of an emergency when parents cannot be reached: Name & Address:
1: 2: 3:
Name of public or private school child attends, if any:
Child's Physician or Clinic's Name (Child's Primary Health Source):
My child has the following special need(s):
The following special accommodation(s) may be required to most effectively meet my child's needs while at this center.
My child is currently on medication(s) prescribed for long-term continuous use and/or has the following pre-existing illness, allergies, or health concerns:
Name (Parent/Guardian) (Signatures needed upon visit to the facility)	Date