Parent/Guardian Name *

First Name

Last Name

Phone *

(###)

###

####

Child First and Last Name *

First Name

Last Name

Has your child ever been kicked out of a daycare or preschool program? *

Yes

No

Blessed Beginnings charges a set weekly tuition rate, based off the child's age, that must be paid regardless of attendance. Please indicate that you understand this. *

Yes, I understand that I must pay my set weekly tuition rate regardless of attendance.

Blessed Beginnings provides childcare that operates out of our personal home. Please indicate that you understand and acknowledge you are aware of this. *

Yes, I understand that Blessed Beginnings operates out of a personal home.

As a State regulated childcare, it is mandatory that all children be fully vaccinated to attend our program. We do not accept unvaccinated children under any circumstances. Please indicate you understand this. *

Yes my child is up to date on all vaccines and I can provide an updated shot record if my child enrolls at Blessed Beginnings.

My child is behind on some vaccines but we have a schedule with their doctor to get them caught up.

What is your estimated/desired enrollment date at Blessed Beginnings *

MM

DD

YYYY

Blessed Beginnings is a home-based childcare, not a center. As such, there may be occasions when we need to close unexpectedly. It is important that families have alternate or back-up care arrangements in place. Please confirm that you understand and accept this policy. *

Yes, I confirm and accept this policy.

Does your child have any allergies, medical conditions, or dietary restrictions? *

Yes

No

Is your child currently potty-trained, in the process, or still in diapers? *

Potty-trained

In the process of being potty-trained

Still in diapers