Application for Admission

Note: Please fill out a separate form for each child you are seeking to enroll at Saint Francis Day Care Center.

Date: *

Month

Day

Year

Date Needing Care: *

Month

Day

Year

Family Name: *

Mother: *

Father: *

Address: *

City: *

State: *

Zip Code: *

Phone Number: *

Marital Status: *

Name of Child for whom placement is requested (Last, First, Middle): *

Date of Birth: *

Month

Day

Year

Place of Birth Hospital Name: *

Sex: *

Days of Week the child will attend: *

Hours of Day child will attend: *

Mother's Employer: *

Hours: *

Mother's Employer phone number:

Mother's Employer address: *

Father's Employer: *

Hours Worked: *

Father's Employer phone number:

Father's Employer address: *

Has the child had previous Day Care placement?:

If yes, Name and Address of previous Center(s):

Other Members of Household including children not in Day Care, in age order:

Additional Comments:

How did you find out about us?

Email Address: *

Leave this field blank

"Let the children come to Me for theirs is the Kingdom of Heaven." Luke 18:16