Preschool/Daycare Enrollment Please provide the following information about your child. Child's Name * Child's Date of Birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year2015201620172018201920202021202220232024 Gender * Male Female Tell us about your child's personality. * Parent/Guardian Information Main e-mail for parents/guardians Parent or guardian #1's name * Phone number * Relationship to child * Parent or guardian #2's name Phone number Relationship to child Does the child live at more than one address weekly? (Example: Shared Custody) * Yes No About Your Child Is your child potty trained? (for 2 years and older) * Yes No Does your child have siblings who attend Oakhurst presently or in the past? * Yes No If yes, please list their names Does your family qualify for assistance with tuition through Connect or Link Resource and Referral? * Yes No What date are you looking for care to start? * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20192020202120222023 Has your child been in daycare before? * Yes No If so, please list each center. Reason for leaving each center: To better serve your child and family needs, please list any disability or referral your pediatrician has made for your child. Has your child received services through the Birth to Three program? Yes No If yes, list the services your child has participated in. Occupational Therapy Speech Therapy Dietary Physical Therapy Other (list these in the box below) Please list any other services. Has your child received services from a mental health professional? Yes No Please list any food allergies your child has. Please list any environmental allergies your child has. Does your child require an EpiPen? Yes No Your application is being submitted to our directors. We will require your family to attend a family tour and meeting with one of our directors before full enrollment occurs. We keep an extensive waiting list and will assign you a spot on that list within 5 days of receiving your request. Our goal is to keep our classrooms full and serve the families in our community and surrounding areas. CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions.