1. Enrollment/Contact Information
Child’s Name:
_________________________________________________________
Child’s Age: ___________________________ D.O.B:
________________________
Home Address:
________________________________________________________
Home Phone:
__________________________________________________________
E-mail:
_______________________________________________________________
_
Mother’s Name:
________________________________________________________
Employer: __________________ Address:
_________________________________
Work Phone: ________________________ Cell Phone:
______________________
Father’s Name
_________________________________________________________
Employer: ___________________ Address:
________________________________
Work Phone: ______________________ Cell Phone:
________________________
Emergency Contact Person:
Name: _______________________________ Phone:
___________________________
Name: _______________________________ Phone:
___________________________
Date of Enrollment:
____________________________________________________

2. I, _________________________________, agree to the weekly rate of
$________ for the enrollment of my child,
____________________________________________.
I, _____________________________, agree to inform Lady Bug’s
Child Care Center of any changes of the above information
and to keep this file up to date.
Name: ___________________________ Date:
__________________
Melissa’s Home: 719.597-5141
Cell: 719.964-6738
E-mail: Melissa@ladybugschildcare.com