Enrollment Form

* = Required Information

Admission Date *

Program *

Student's Name *

Classroom *

Student's Date of Birth *

Enrolling Parent's Name

Mobile/SMS Phone Number

Student's Home Address

City

Zip Code

Email Address *

Home Phone Number

Is the child on any medication, including vitamins?

Yes

Please list

Date of last physical

Are you currently enrolled CCIS subsidy?

Yes

Which county?

Pike County

Monroe County

Is there a court/custody order in place?

Yes

Cash

Check

MC/Visa/Amex

I agree to promptly notify PMCA of any changes to the above information. Providing false information can result in termination of childcare services.

Enrolling Parent's Name

Date