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APPLICATION: ONE-TIME FAMILY FEE: $200.00

Please Enter Academic Year Here
Please Enter Ideal Start Date Here
Please Enter Child's Name Here
Please Enter Date of Birth Here
Please Enter Place of Birth Here
Please Enter Family Mail Address Here
Please Enter City Here
Please Enter Zip Code Here

Guardian 1

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Please Enter Guardian Name Here
Please Enter Cell Number Here
Please Enter Email Address Here

Guardian 2

In case of an emergency, who can we call if we are unable to reach you

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PLEASE CHOOSE BELOW A SCHEDULE AND TIME FOR THE ACADEMIC YEAR, SEPTEMBER - JUNE

Medical Statements and Consent

Petits Poussins Daycare is not permitted to administer any medication, if needed, please do so at home or after school.

I (we) authorize staff and Director of Petits Poussins Daycare to obtain all necessary Emergency Medical treatment, in case of an emergency.

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Note: All allergies/medical conditions must be stated on the child's medical form. Additionally, a "Standing Order" from the Pediatrician will be required in order to administer an Epi-Pen, Benadryl, or any Asthma medication. Your child will not be admitted without it.

New York department of health requires that all children are vaccinated for school entrance.

I, hereby, authorize Petits Poussins Daycare to provide care for my child.

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I declare to the best of my knowledge that all statements made in this application are true.

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