Child(ren) Information

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

Select the number of children being registered for the Olivia Haverkamp Early Learning Center.required

Admin Override

Child One

First Namerequired

Preferred/Nickname

Middle Namerequired

Last Namerequired

Gender*

Female Male

Date of Birthrequired (mm/dd/yyyy)

Does this child have any special social or physical needs?*

Yes No

Please explainrequired

Please provide any additional information about this child that may be relevant to their participation in childcare, including any current or previous childcare experience.

Select the preferred days this child will be attending the Olivia Haverkamp Early Learning Center.*

Five Days (Mon - Fri) Three Days (Mon / Wed / Fri) Two Days (Tues / Thurs)

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

Yes No

What would your ideal schedule be?required

Child Two

First Namerequired

Preferred/Nickname

Middle Namerequired

Last Namerequired

Gender*

Female Male

Date of Birthrequired (mm/dd/yyyy)

Does this child have any special social or physical needs?*

Yes No

Please explainrequired

Please provide any additional information about this child that may be relevant to their participation in childcare, including any current or previous childcare experience.

Select the preferred days this child will be attending the Olivia Haverkamp Early Learning Center.*

Five Days (Mon. - Fri.) Three Days (Mon / Wed / Fri) Two Days (Tues / Thurs)

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

Yes No

What would your ideal schedule be?required

Child Three

First Namerequired

Preferred/Nickname

Middle Namerequired

Last Namerequired

Gender*

Female Male

Date of Birthrequired (mm/dd/yyyy)

Does this child have any special social or physical needs?*

Yes No

Please explainrequired

Please provide any additional information about this child that may be relevant to their participation in childcare, including any current or previous childcare experience.

Select the preferred days this child will be attending the Olivia Haverkamp Early Learning Center.*

Five Days (Mon - Fri) Three Days (Mon / Wed / Fri) Two Days (Tues / Thurs)

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

Yes No

What would your ideal schedule be?required

Additional Information

Would you like to schedule a tour of the ELC?*

Yes I have already taken a tour. No

Tour Date Preference*

Thursday, June 18, 8:30 - 9:30 am Friday, June 26, 10:00 - 11:00 am Thursday, July 16, 8:30 - 9:30 am Friday, July 24, 10:00 - 11:00 am I will contact the ELC to schedule a tour.

Do you have any specific questions for staff to answer during your visit?

Which of the following GRCS programs do you hope to enroll your child(ren) in?*

Primary Home Address for Child(ren)

Addressrequired

Cityrequired

Staterequired

Ziprequired

Parent/Guardian Information

Select the number of parent(s)/guardians(s) for the child(ren) being registered.required

Parent/Guardian One

First Namerequired

Preferred Name

Last Namerequired

Relation to childrequired

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

Is this parent a graduate of Grand Rapids Christian High School?*

Yes No

Parent/Guardian Two

First Namerequired

Preferred Name

Last Namerequired

Relation to childrequired

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

Is this parent a graduate of Grand Rapids Christian High School?*

Yes No

Sibling Information

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

First Namerequired

Last Namerequired

Date of Birthrequired (mm/dd/yyyy)

Is this child a current GRCS student?*

Yes No

First Namerequired

Last Namerequired

Date of Birthrequired (mm/dd/yyyy)

Is this child a current GRCS student?*

Yes No

First Namerequired

Last Namerequired

Date of Birthrequired (mm/dd/yyyy)

Is this child a current GRCS student?*

Yes No

First Namerequired

Last Namerequired

Date of Birth required (mm/dd/yyyy)

Is this child a current GRCS student?*

Yes No

First Namerequired

Last Namerequired

Date of Birth required (mm/dd/yyyy)

Is this child a current GRCS student?*

Yes No

Other

Please list any additional questions, comments, or requests.