To Enroll….

Parents enrolling your child into our programs:

Young Toddler and Older Toddlers must be at least 12 months old
Free PreK for preschoolers must be 3 or 4 years old before September 1st

Payment

Visa, Mastercard, American Express, and Discover

To Apply….

Here at Heavenly Daycare we have taken the time to speed up and streamline the enrollment process. Please take 15 minutes to fill out and submit the form below. We will contact you afterwards to answer any questions you may have and finalize your child’s enrollment.

Child's Information

Child's Name(Required)

First Middle Last

Child's Birthday(Required)

Please provide two digit month (MM), two digit date (DD) and four digit year (YYYY)

Child's Age(Required)

Child's Sex(Required)

Female

Male

Child's Full Address(Required)

Street Address Address Line 2 City State ZIP Code

Primary Language(Required)

Primary Language (Other)(Required)

Please provide primary language.

Child's Race(Required)

Child's Race (Other)(Required)

Please specify the child's race.

Does the child currently live in a shelter, transitional or rapid rehousing, or temporarily living in someone else’s house?(Required)

Yes

Has your child previously received childcare services?(Required)

Yes

If, Yes (Where , When , Why did they leave that program?)(Required)

Does your child have a current Individualized Family Service Plan (IFSP) or Individualized Education Plan (IEP)?(Required)

Yes

Are there any custody orders or arrangements that we should be aware of?(Required)

Yes

Do any of these special needs require special care from our teachers?(Required)

Yes

Is your child toilet trained?(Required)

Yes

Parents and Family Information

Caregiver One:

This should be the parent/guardian filling out this form.

Parent/Guardian's Name(Required)

First Last

Parent/Guardian's Phone Number(Required)

Parent/Guardian's Email(Required)

Parent/Guardian's Relationship to Child(Required)

Parent/Guardian's Relationship to Caregiver Two(Required)

Is Your Address the Same as the Child Being Enrolled?(Required)

Yes

Caregiver One Address(Required)

Street Address Address Line 2 City State Zip Code

Place of Employment (Business Name)(Required)

Address of Employment(Required)

Street Address Address Line 2 City State ZIP Code

Phone Number of Employment(Required)

Caregiver Two:

Parent/Guardian's Name

First Last

Parent/Guardian's Phone Number

Parent/Guardian's Email

Parent/Guardian's Relationship to Child

Parent/Guardian's Relationship to Caregiver One

Is Caregiver Two's Address the Same as the Child Being Enrolled?

Yes

Caregiver Two Address

Street Address Address Line 2 City State ZIP Code

Place of Employment (Business Name)

Address of Employment

Street Address Address Line 2 City State ZIP Code

Phone Number of Employment

Additional Information

Expected Start/Enrollment Date(Required)

Please provide two digit month (MM), two digit date (DD) and four digit year (YYYY)

Which of the following programs interest you?(Required)

Childcare

Before and After Care

PHLpreK

PreK Counts

How'd you hear about us?(Required)

If Other, Please Specify

Emergency Contacts

You will need a minimum of three emergency contacts. If you are unable to provide them at this time, we will gather that information when you visit our location.

Emergency Contact 1:

Name (Emergency Contact 1)

First Last

Phone (Emergency Contact 1)

Address (Emergency Contact 1)

Street Address Address Line 2 City State ZIP Code

Relationship to Child (Emergency Contact 1)

Does Emergency Contact 1 Have Permission to Pick Up or Drop Off Child?

Yes

Emergency Contact 2:

Name (Emergency Contact 2)

First Last

Phone (Emergency Contact 2)

Address (Emergency Contact 2)

Street Address Address Line 2 City State ZIP Code

Relationship to Child (Emergency Contact 2)

Does Emergency Contact 2 Have Permission to Pick Up or Drop Off Child?

Yes

Emergency Contact 3:

Name (Emergency Contact 3)

First Last

Phone (Emergency Contact 3)

Address (Emergency Contact 3)

Street Address Address Line 2 City State ZIP Code

Relationship to Child (Emergency Contact 3)

Does Emergency Contact 3 Have Permission to Pick Up or Drop Off Child?

Yes

Emergency Contact 4:

Name (Emergency Contact 4)

First Last

Phone (Emergency Contact 4)

Address (Emergency Contact 4)

Street Address Address Line 2 City State ZIP Code

Relationship to Child (Emergency Contact 4)

Does Emergency Contact 4 Have Permission to Pick Up or Drop Off Child?

Yes

Name

This field is for validation purposes and should be left unchanged.

To Enroll….

Parents enrolling your child into our programs:

Your toddler must be at least 13 months old
Your preschooler must be at least 3 years old

To Apply….

Please download and fill out the following PDF documents.

Then, please either 1) print and return the PDF documents in person, or 2) email them to heavenlydaycare3@gmail.com:

Child Health Report

Day Care Agreement

Emergency Contact / Parental Consent Form

Child’s Dental Report

School Year 2020-2021 PHLpreK Application

PHLpreK Enrollment Confirmation

Screening, Assessment, and Data Sharing Release Form 2020‐2021 School Year

Reach for the Stars Food Service

Payment

Visa, Mastercard, American Express, and Discover

Enroll

To Enroll….

Payment

To Apply….

Child's Information

Parents and Family Information

Caregiver One:

Caregiver Two:

Additional Information

Emergency Contacts

Emergency Contact 1:

Emergency Contact 2:

Emergency Contact 3:

Emergency Contact 4:

To Enroll….

To Apply….

Payment

Heavenly Daycare & Learning Center

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