Childcare Enrollment Form

For new children

Child's Full Name

Birth date

Sex assigned at Birth

Female

Male

Full Name Parent 1

Birthdate Parent 1

Full Mailing Address (Street City State Zip)

Parent 1 Phone

Email Parent 1

Employer Parent 1

Work Phone Parent 1

Full Name Parent 2

Birthdate Parent 2

Full Mailing Address for Parent 2

Parent 2 Phone

Email Parent 2

Employer Parent 2

Please list names, birthdates and relationships of other household members

What languages are spoken in your home?

To help us best support your child and family, please share the following with us.

Please tell us about your child and your family:

Please share what inspires you to have your child in Sophia's Hearth Childcare Program.

Does your child have any medical contditions or allergies?

Has your child received any developmental evaluations? Is your child receiving any supportive services?

Please list previous and current care arrangements for your child (including dates).

The rhythms of daily life form a foundation for our care of the children. Information about your child's daily habits would be helpful to us in this planning.

Please describe your child's eating habits

Please describe your child's sleep habits.

Please describe where your child is in relationship to independent toileting (if applicable).

Your Signature

A payment of $550 ($50 one-time registration, $500 deposit) must accompany this form submission. The $500 deposit will not be refundable until the contract starts and will then be held to apply to the final weeks of tuition.

Thank you. The form is complete.

After clicking the "proceed to pay deposit" button a pop up screen will appear to complete the payment. It sometimes takes up to 10 seconds so please be patient. The form will not be submitted unless the fee is paid.

Payment can be made by Mastercard, Visa, Discover, Amex, or PayPal