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Enrollment Form

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Child Enrollment Application and Parent Interview Form

16280 NW Bethany Ct.
Beaverton, OR 90076-4885

(503)713-5330

Step 1 of 5 - Child's Information

Child's Information
Child's Name
First Last
Nickname
Child's Date of Birth
MM slash DD slash YYYY
Projected Enrollment Date
MM slash DD slash YYYY
Child's Age
Parent's Email Address
Has your child had previous experience in child care?
- Yes
- No
Type of Care
How Long?

Family History
Mother's Name
First Last
Age
Mother's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Father's Name
First Last
Age
Father's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Mother is employed outside the home?
- Yes
- No
If yes, Mother's Place of Employment
Work Hours
Work Phone
Father is employed outside the home?
- Yes
- No
If yes, Father's Place of Employment
Work Hours
Work Phone
Is this child (or family) working with any social service agency?
- Yes
- No