christian pentecostal day care’s ONLINE APPLICATION

Roberta C. Hardy, Executive Director

Please Select the School you are interested in:

971 Clinton Avenue

717 Grove Street

CHILD'S INFORMATION

Child's Name

First Name

Last Name

Child's Date of Birth

MM

DD

YYYY

Child's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name by which child is Most often Called

Doctor Prescribed Food Restrictions / Allergies

MOTHER'S INFORMATION

Mother's Name

First Name

Last Name

Employed By

Employers Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Hours of Employment

Phone Number

(###)

###

####

Cell Phone Number

(###)

###

####

FATHER'S INFORMATION

Father's Name

First Name

Last Name

Employed By

Employers Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Hours of Employment

Phone Number

(###)

###

####

Cell Phone Number

(###)

###

####

EMERGENCY CONTACTS / PICK UP LIST

Name

First Name

Last Name

Relation

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Name

First Name

Last Name

Relation

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

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TERMS OF ACCEPTANCE and SIGNATURE

Upon signing this document I indicate my child is in good health and condition to attend aftercare program. I further give Seasons of Learning, Christian Pentecostal Day Care and/or its staff, permission to have my child medically treated in case of any medical emergency while in attendance and/or on a trip.

Name

First Name

Last Name

Email

I, the [applicant, requestor, etc.] for this [type of form], warrant the truthfulness of the information provided in this application.

Electronic Signature

Please type your First and Last Name

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.

christian pentecostal day care’s ONLINE APPLICATION

Roberta C. Hardy, Executive Director

© 2022 Christian Pentecostal DAY CARE’S

Main location and Mailing Address:

971 Clinton Avenue

Irvington, New Jersey 07111

973-399-7000 ext. 0
CONTACT US