FBC Early Childhood Learning Center Registration

Please fill out this form and click submit.

Child Information

Child's Full Name

*

Name/Nickname

*

Child's Date of Birth

*

Child's Gender

*

Please select all that apply.

Male Female

Allergies or Medical Conditions:

*

Medications:

*

Parent/Guardian 1 Information

Full Name

*

Relationship to Child

*

Address

*

Phone

*

Email

*

This address will receive a confirmation email

Parent/Guardian 2 Information

Full Name

*

Relationship to Child

*

Address

*

Phone

*

Email

*

This address will receive a confirmation email

Pickup Authorization

List anyone authorized to pickup your child outside of the listed parents/guardians.

Name

*

Relationship to Child

Phone

Email

Name

*

Relationship to Child

Phone

Email

Name

*

Relationship to Child

Phone

Email

Health and Safety Information

Primary Care Physician:

*

Preferred Hospital

*

Special Needs or Accommodations

*

Development and Learning

Does your child have experience in a preschool or daycare setting?

*

Please select all that apply.

Yes No

Potty Training Status:

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Please select one option.

Fully Trained In Progress Not Started Yet

Learning Strengths / Interests:

*

Areas You Would Like Support:

*

Enrollment Preferences

Program Interested In:

*

Please select one option.

Preschool Only (8:00AM - 12:00PM) Preschool and Extended Care (8:00AM-3:00PM)

Desired Start Date

*

Faith and Values

Are you an active member at FBC Blakely?

*

Please select all that apply.

Yes No

Church Affiliation:

*

Special notes regarding faith-based instruction:

*

Additional Information

Please share any information you feel is important for us to know about your child:

*

I understand that submission of this form does not guarantee enrollment and that placement is based on availability and program requirements. By clicking

*

Please select all that apply.

I Agree

Registration Payment $75

Credit/Debit Card Number

Expiration Date/CVC

Name on Card

Card Billing Address

Description

Please fill out this form and click submit.

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