Child(ren) Information

A $100 non-refundable / non-transferable registration fee (per child) is required upon submission.

Registrantsrequired

Please select the number of children being registered for the Olivia Haverkamp Early Learning Center.

Admin Override

Child One

First Namerequired

Preferred/Nickname

Middle Namerequired

Last Namerequired

Gender*

Female Male

Date of Birthrequired (mm/dd/yyyy)

Does this student have any special social needs?*

Yes No

Please explainrequired

Does this student have any special physical needs?*

Yes No

Please explainrequired

Additional Information

Please provide any additional information about this child that may be relevant to their participation in childcare.

Registration Options — Child One

Olivia Haverkamp Early Learning Center*

Please select the preferred days this child will be attending the Olivia Haverkamp Early Learning Center.

Five Days (Mon - Fri) - $295/wk Three Days (Mon / Wed / Fri) - $195/wk Two Days (Tues / Thurs) - $150/wk

Are you interested in a different schedule while you wait for an opening in your preferred schedule?*

Yes No

Please explain what your ideal schedule would berequired

Child Two

First Namerequired

Preferred/Nickname

Middle Namerequired

Last Namerequired

Gender*

Female Male

Date of Birthrequired (mm/dd/yyyy)

Does this student have any special social needs?*

Yes No

Please explainrequired

Does this student have any special physical needs?*

Yes No

Please explainrequired

Additional Information

Please provide any additional information about this child that may be relevant to their participation in childcare.

Registration Options — Child Two

Olivia Haverkamp Early Learning Center*

Please select the preferred days this child will be attending the Olivia Haverkamp Early Learning Center.

Five Days (Mon. - Fri.) - $295/wk Three Days (Mon / Wed / Fri) - $195/wk Two Days (Tues / Thurs) - $150/wk

Are you interested in a different schedule while you wait for an opening in your preferred schedule?*

Yes No

Please explain what your ideal schedule would berequired

Child Three

First Namerequired

Preferred/Nickname

Middle Namerequired

Last Namerequired

Gender*

Female Male

Date of Birthrequired (mm/dd/yyyy)

Does this student have any special social needs?*

Yes No

Please explainrequired

Does this student have any special physical needs?*

Yes No

Please explainrequired

Additional Information

Please provide any additional information about this child that may be relevant to their participation in childcare.

Registration Options — Child Three

Olivia Haverkamp Early Learning Center*

Please select the preferred days this child will be attending the Olivia Haverkamp Early Learning Center.

Five Days (Mon - Fri) - $295/wk Three Days (Mon / Wed / Fri) - $195/wk Two Days (Tues / Thurs) - $150/wk

Are you interested in a different schedule while you wait for an opening in your preferred schedule?*

Yes No

Please explain what your ideal schedule would berequired

Primary Home Address for Child(ren)

Addressrequired

Cityrequired

Staterequired

Ziprequired

Parent/Guardian Information

Parent(s)/Guardian(s)required

Please select the number of parent(s)/guardians(s) for the student(s) being registered.

Parent/Guardian One

First Namerequired

Preferred Name

Last Namerequired

Relation to childrequired

Parent/Guardian Responsibility

Please check ALL that apply.

Contact Allowed: Indicates the parent/guardian is allowed contact with the child(ren).

Has Custody: Indicates the parent/guardian has legal custody of the child(ren).

Mail/Email Allowed: Indicates the parent/guardian may receive mail or email regarding the child(ren).

Release To: Indicates the ELC may release the child(ren) to the parent/guardian.

Financial Responsibility: Indicates the parent/guardian is responsible for childcare payments.

Emailrequired

Phonerequired

Address same as child(ren)?*

Yes No

Addressrequired

Cityrequired

Staterequired

Ziprequired

Parent/Guardian Two

First Namerequired

Preferred Name

Last Namerequired

Relation to childrequired

Parent/Guardian Responsibility

Please check ALL that apply.

Contact Allowed: Indicates the parent/guardian is allowed contact with the child(ren).

Has Custody: Indicates the parent/guardian has legal custody of the child(ren)

Mail/Email Allowed: Indicates the parent/guardian may receive mail or email notifications regarding the child(ren).

Release To: Indicates the ELC may release the child(ren) to the parent/guardian.

Financial Responsibility: Indicates the parent/guardian is financially responsible for childcare payments.

Emailrequired

Phonerequired

Address same as child(ren)?*

Yes No

Addressrequired

Cityrequired

Staterequired

Ziprequired

Sibling Information

Siblingsrequired

Does your child(ren) have additional siblings not previously listed on this form?

First Namerequired

Last Namerequired

Date of Birthrequired (mm/dd/yyyy)

GRCS Student*

Is this child a current GRCS student?

Yes No

First Namerequired

Last Namerequired

Date of Birthrequired (mm/dd/yyyy)

GRCS Student*

Is this child a current GRCS student?

Yes No

First Namerequired

Last Namerequired

Date of Birthrequired (mm/dd/yyyy)

GRCS Student*

Is this child a current GRCS student?

Yes No

First Namerequired

Last Namerequired

Date of Birth required (mm/dd/yyyy)

GRCS Student*

Is this child a current GRCS student?

Yes No

First Namerequired

Last Namerequired

Date of Birth required (mm/dd/yyyy)

GRCS Student*

Is this child a current GRCS student?

Yes No

Other

Please list any additional questions, comment or requests.