Enrollment Application

For questions pertaining to available openings, or enrollment please fill out the form below.

For tour information, please call us at +1.765.447.7044, or visit our Contact page.

Note: There is a $55 registration fee that must be paid prior to starting date of care.
Note: Online Summer Camp enrollment applications must be submitted no later than May 20th. Forms must be submitted in person after this date.
Note: '*' indicates required field

Name *
Name
Contact Number *
Contact Number
Child/rens Information
Child Name *
Child Name
Date of Birth *
Date of Birth
Gender *
Attended Child Care Before *
Address *
Address
Primary Care Physician *
Primary Care Physician
PCP Phone Number *
PCP Phone Number
(Primary Care Physician)
List all medications, medical conditions, or allergies
Additional Children
Child Name
Child Name
Date of Birth
Date of Birth
Gender
Attended Child Care Before
Address
Address
Primary Care Physician
Primary Care Physician
PCP Phone Number
PCP Phone Number
(Primary Care Physician)
List all medications, medical conditions, or allergies
Parent/Guardian Information
Parent/Guardian Name *
Parent/Guardian Name
Select All That Apply *
Cellular Phone Number *
Cellular Phone Number
Work Phone Number *
Work Phone Number
Parent/Guardian Name *
Parent/Guardian Name
Select All That Apply *
Cellular Phone Number *
Cellular Phone Number
Work Phone Number *
Work Phone Number
Emergency Contact Information
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Number *
Emergency Contact Number
Emergency Contact Address *
Emergency Contact Address
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Number *
Emergency Contact Number
Emergency Contact Address *
Emergency Contact Address