Child's Information:

Full Name

Address

Street Address

City

State

Country

Postal Code

Date of birth

Enrolling Parent/Guardian Name

Gender:

Male

Female

Parent/Guardian Information:

First Name

Last Name

Child Resides with

Mother

Father

Both

Other

Parenting plan in place?

If yes, a copy must be provided to WCFCI before the child's first day of attendance.

Mother's Employer

Mother's Email Address

Mother's Phone:

Father's Employer

Father's Email:

Father's Phone

Father's Signature

Mother's Signature

Today's Date:

Date your child will enter program: