Shaynah Kinner Center, LLC
| "Your Child's Home Away from Home" |
| TEMPLATE, (Official Form Coming Soon!!!!) Child’s Name ______________________________________________________ (Last Name) (First Name) (Initial) Child’s Address ____________________________________________________ Child’s Address ____________________________________________________ City __________________State _______ Zip _________ Phone # ____ - ____- _____ Date of Birth __________ Sex M F Child’s Social Security # ______- _____- _______ (Not Required) Circle days to attend AM Mon Tues Wed Thurs Fri Arrival Time _____ : ______ Departure Time ______ : ______ PM Mon Tues Wed Thurs Fri Arrival Time _____ : ______ Departure Time _____ : ______ Meals to attend AM Snack Lunch PM Snack School-age Out of Session days to attend Mon Tues Wed Thurs Fri Arrival Time ____ : ____ Departure Time ____ : _____ School-age Out of Session meals to attend AM Snack Lunch PM Snack Enrolling Parent/Guardian Name _________________________________________ (Last Name) (First Name) (Initial) Relationship to Child ____________ Drivers License # _________________ State _____ Address __________________________________ City_____________________ State __________ Zip _________ E-mail Address _________________________ Home Phone # ______________________ Cell Phone # ______________________ Employer ____________________________________ Work Phone # _________________________ Extension # ___________ Address ______________________________ City ______________________ State _______Zip _________ Work Hours ________________________ Parent/Guardian Name ______________________________________________ (Last Name) (First Name) (Initial) Relationship to Child __________________ Drivers License # _______________ State _____ Address ________________________________________ City ____________________________ State _________ Zip __________ E-mail Address __________________________ Home Phone # ___________________________ Cell Phone # ___________________ Employer _____________________________ Work Phone # ________________ Extension # _______________ Address ________________________________________ City________________________ State _______ Zip ___________ Work Hours ___________________________ Drivers License # ___________________________ State _________ Parents Marital Status Married Divorced Single Child's Primary Residence (check) Both ____Mother ______ Father _____Guardian ____ If divorced, who has legal custody? _______________________ May the non-custodial parent pick up the child? ( circle) Yes No Enrolling Parent/Guardian Signature _________________________________________ Date ____________ |
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| Print out form and mail or fax to: Shaynah Kinner Day Care Center LLC 205 James Street Kutztown, PA. 19530 Phone (610)683-5040 Fax (610)641-9170 shaynahkinner@hotmail.com |