Nursery Enrollment Registration

Contact Deana at 696-5229 for more information.

Name(s) ~ Required

Email ~ Required

Phone ~ Required

Childs name ~ required

Nickname

If applicable

Birth Date ~ required

Todays date ~ required

Parent or Guardian name ~ required

Sibling names and ages

Mailing address ~ required

City state zip ~ required

Home Phone ~ required

Work or other phone ~ required

Other Safe Adults ~ required

In emergency situations

List any known allergies

For example Michelle:milk John:peanuts

Are snacks okay ~ required

Please answer yes or no

Please describe any special needs or issues that your child has that will help the staff care for your child