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Enrollment Form

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Child Enrollment Application and Parent Interview Form

16280 NW Bethany Ct.
Beaverton, OR 90076-4885

(503)713-5330

Step 1 of 5 - Child's Information

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Child's Information
Child's Name
First Last
Nickname
Child's Date of Birth
Date Format: MM slash DD slash YYYY
Projected Enrollment Date
Date Format: MM slash DD slash YYYY
Child's Age
Parent's Email Address
Has your child had previous experience in child care?
- Yes
- No
Type of Care
How Long?

Family History
Mother's Name
First Last
Age
Mother's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Father's Name
First Last
Age
Father's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Mother is employed outside the home?
- Yes
- No
If yes, Mother's Place of Employment
Work Hours
Work Phone
Father is employed outside the home?
- Yes
- No
If yes, Father's Place of Employment
Work Hours
Work Phone
Is this child (or family) working with any social service agency?
- Yes
- No

People Authorized To Pick Up This Child
List of Authorized
Name Address Relationship to Child
Please note that a copy of Divorce Decree or other official document will be required, on file, should one or both of the child's parents be listed here!
Emergency Information
We always try to contact parents first. However, we are required to have an emergency contact other than parents. These people are also authorized to pick up your child from the facility. Please list all phone numbers appropriate:
Contacts
Name Address Relationship to Child Cell Phone Home Phone Business Phone