Enrollment & Forms

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Location

Enrollment Date

Childs Name

First

Last

Address

Address Line 1

City

State

Zip Code

Mothers Name

First

Last

Mother's Place of Employment

Mother's Work Phone

Mother's Cell Phone

Mother's Email

Father's Name

First

Last

Address

Address Line 1

City

State

Zip Code

Driver's License Number

Social Security

Father's Work Phone Number

Father's Cell Phone Number

Father's Email

The child may be released to the person(s)signing this ageement or to the following:

01

Name

Phone

Address

Address Line 1

City

State

Zip Code

Relationship to child, Relationship to parent(s) or guardian or any other identifying information, If any:

02

Name

Phone

Address

Address Line 1

City

State

Zip Code

03

Name

Phone

Address

Address Line 1

City

State

Zip Code

Relationship to child, Relationship to parent(s) or guardian or any other identifying information, If any:

Persons to contact in the case of emergency when parent or guardian cannot be reached:

01. Name & Number

02. Name & Number

03. Name & Number

Name of public or private schools child attends, if any

Child's doctor or clinic name:

Email currently information,

Phone

My child has the following special needs:

The following special accommodation(s) may be required to most effectively meet my child's needs while at the center:

My child is currently on medication(s) prescribed for long-term continuous use and/or has the following pre-existing illness, allergies (food, insect, medications, etc.) or health concerns:

EMERGENCY MEDICAL AUTHORIZATION

Should suffer an injury or illness while in the care of Smarty Pants Academy and the facility is unable to contact me (us) immediately, it shall be authorized to secure such medical attention and care for the child as may be necessary. I (We) shall assume responsibility for payment for services.

Signature

Clear Signature

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Today's Date

Your name (required)

First

Last

Your email (required)

Phone number

Child's Name 1:

Birthdate:

Child's Name 2:

Birthdate:

Child's Name 3:

Birthdate:

Address

Address Line 1

City

State

Zip Code

Name

First

Last

Potential Start Date:

I need childcare for:

Preferred Tour/Viewing Date:

childcare Layout Confirm

Is there anything you will like us to know to get ready for your tour?

Confirm You are not a Robot:

01

02

03

EMERGENCY MEDICAL AUTHORIZATION

Locations

601 9Th Avenue Port Arthur, Texas 77642

Phone & Email

+409 999-6226

In@**********my.com

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