Date of Application

MM

DD

YYYY

Child Information *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Contact Number: *

Country

(###)

###

####

Primary Parent/Guardian *

First Name

Last Name

Phone *

Country

(###)

###

####

Home Address *

If different from child's

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Secondary Parent/Guardian *

First Name

Last Name

Phone *

Country

(###)

###

####

Emergency Contact *

Other than Parents/Guardians

First Name

Last Name

Phone *

Country

(###)

###

####

Does your child have any allergies or medical conditions? *

No

Yes

Does your child have any dietary restrictions? *

No

Yes

Has your child been diagnosed with any developmental, sensory, or learning needs? *

No

Yes

Does your child require any medication during daycare hours? *

No

Yes

Preferred Start Date: *

MM

DD

YYYY

Preferred Days of Care *

Select all that apply

Monday

Tuesday

Wednesday

Thursday

Friday

Preferred Drop-off Time *

Hour

Minute

Second

AM PM

Preferred Pick-up Time *

Hour

Minute

Second

AM PM

Are there any custody arrangements or authorized pick-up restrictions *

No

Yes

Parent/Guardian Agreement *

I acknowledge that completing this application does not guarantee a spot at Heritage Daycare. I understand that a separate enrollment confirmation and contract will be provided upon acceptance.

I agree

Date of Signing *

MM

DD

YYYY