Child’s Name:

Potty Trained? Y N

Birth Date (mmddyy)

Father:

Mother:

Legal Guardian (s):

Address:

City

 Zip:

Home Phone

Father’s Work Cell

Mother’s Work Cell

Legal Guardian's work Cell

Email Address:

Date you would like to enroll your child

Hours you will need childcare

Days you will need childcare

Is your child currently enrolled in a childcare or in-home care facility?


**Please note that this form does not guarantee placement in Cornerstone Christian Childcare Center.

**Virginia Department of Social Services regulates the ratio of children to caregivers/teachers. Cornerstone Christian Childcare Center will abide by their standards or exceed them. For this reason we must accommodate families on a first come first serve basis.