Deliverance Ministry Childcare Learning Center

Online enrollment information

This emails your completed form directly to the daycare. The center will arrange required signatures, including emergency authorization and activity permissions before enrollment is finalized. Thank you

Fields marked * are required. Additional contacts can be provided to the center.

Child and family informationChild's name *Name child is known byChild's birthdate *Child's home address *Name(s) of parent(s)/guardian(s) *Home telephone number *Address of parent(s)/guardian(s) *Mother's employerFather's employerMother's email addressFather's email addressMother's employer addressFather's employer addressMother's employer telephone numberFather's employer telephone numberOther telephone numbers (cellular phone, pager, etc.)Instructions for reaching parent/guardian in an emergency *

Emergency contacts1. Name *1. Relationship to child *1. Address *1. Telephone number *2. Name2. Relationship to child2. Address2. Telephone number3. Name3. Relationship to child3. Address3. Telephone number

Child's doctorDoctor's name *Doctor's address *Doctor's telephone number *

Special needsSpecial needs or instructions (write None if none) *

Authorized pickups1. Name *1. Relationship to child *1. Address *1. Telephone number *2. Name2. Relationship to child2. Address2. Telephone number3. Name3. Relationship to child3. Address3. Telephone number4. Name4. Relationship to child4. Address4. Telephone number5. Name5. Relationship to child5. Address5. Telephone number

Parent contact and reviewEmail for follow-up *Name of parent/guardian completing this form *

I am the child’s parent/guardian and agree to submit these details to the daycare for enrollment review. I understand this does not confirm enrollment or replace required signed permissions.