Admission Form | Cherry Hill Learning Center

Child Information:

Child’s Full Name: *

Date of Birth *

GenderMaleFemale

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Primary Language Spoken at Home *

Allergies/Medical Conditions

Special Needs/Accommodations

Dietary Restrictions

Parent/Guardian Information

Full Name *

Relationship to Child *

Email Address *

Phone Number (Home)

Phone Number (Work)

Phone Number (Mobile)

Employer Name

Employer Address

Secondary Parent/Guardian:

Full Name *

Relationship to Child *

Email Address *

Phone Number (Home)

Phone Number (Work)

Phone Number (Mobile)

Employer Name

Employer Address

Emergency Contact 1 (Other than Parents/Guardians):

Name

Relationship to Child

Phone

Authorized to Pick Up Child?YesNo

Emergency Contact 2

Name

Relationship to Child

Phone

Authorized to Pick Up Child?YesNo

Authorized Pick-Up Persons:

Full Name 1

Relationship to Child

Phone

Full Name 2

Relationship to Child

Phone

Health and Medical Information:

Pediatrician’s Name

Pediatrician’s Phone Number

Pediatrician’s Address

Preferred Hospital in Case of Emergency

Health Insurance Provider

Does your child take any regular medication?YesNo

If Yes, please list

Immunization Records: (Attach a copy)

No file chosen

Any additional medical information:

Desired Start Date:

Desired Start Date *

Drop-Off Time

Hours

Minutes

Pick-Up Time

Hours

Minutes

CCAP (Child Care Assistance Program) Information

CCAP Assistance

We proudly accept CCAP from all counties. Please complete the section below if you are enrolling your child with CCAP assistance.

CCAP Case Number

Authorized Hours for CCAP Coverage

CCAP Approval Letter: (Attach a copy)

No file chosen

Name of Caseworker

Caseworker’s Phone Number

Caseworker’s Email Address

Parent/Guardian CCAP Co-Pay Amount (if applicable)

USD

Do you need assistance with your CCAP application?Yesno

Consent and Permissions:

I, the undersigned parent/guardian, authorize [Your Daycare Name] to seek emergency medical treatment for my child in case of a medical emergency. *YesNo

Full Name

Date

Do you consent to your child being photographed or videotaped for use in educational materials, on our website, or in promotional materials? *YesNo

Full Name

Date

Do you grant permission for your child to participate in supervised field trips organized by Cherry Hill Learning Center? *YesNo

Full Name

Date

Parent/Guardian Agreement:

I hereby certify that the information provided on this form is accurate to the best of my knowledge. I agree to adhere to all policies and procedures set forth by Cherry Hill Learning Center. I understand the financial obligations associated with enrolling my child at this center and agree to pay tuition fees promptly.

Parent/Guardian Name *

Date

Admission

Please fill out the form

15500 E Smoky Hill Rd,
Aurora, CO 80015

Tel: (303) 693-5437

15500 E Smoky Hill Rd,
Aurora, CO 80015

Tel: (303) 693-5437