Today's Date

Child's Name

Last

  

First

Date of Birth

Gender

Child's Home address

Mailing address (if different)

Home Telephone Number

Father's/Guardians Name

Mother's/Guardian Name

Current daycare situation

When do you wish to enroll your child?

"Train up a child in the way he should go

and when he is old he will not depart from it."

Proverbs 22:6

WAITLIST APPLICATION

Please fill in the required fields and push submit button on the bottom of the page. You will be contacted when a space becomes available for your child.

Cell Phone #

Cell Phone #

Home with Family Member

At a relative's Home

Daycare/Baby sitter

Other Preschool

Immediately

2012-2013

Boy

Girl

2013-2014