Enrollment Application

First name

Middle answer

Last name

Birthday

Sex

Boy

Girl

City

State

Zip Code

Desired Start Date

Estimated Drop-off Time

Estimated Pick-up Time:

Any known medical conditions/chronic illness? (e.g. asthma, allergies, history of illness):

Special Dietary Needs:

Parent/Guardian’s Information:

Parent/Guardian #1 Full Name:

Relationship

Address (if different):

Cell Phone

Home/Work Phone

Parent/Guardian #2 Full Name:

Relationship

Address (if different):

Cell Phone

Home/Work Phone

Tell Prefered method of contact

How did you hear about us?

Do you have Footsteps affiliation already?

To help with your child’s tracking at Footsteps, what are you thinking after us?

Child’s Siblings

Health Concerns or Special Needs

Current or Previous Services (OT, Speech, etc.)

How do you think you’ll handle separation?

Rate Your Crazy

Your child colors all over the walls right before guests arrive. You're more likely to:

It's picture day and your child refuses to wear the outfit you chose. You’re more likely to:

You finally sit down with a hot coffee and your child immediately needs something. You:

Parent/Guardian Signature

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Fixed price

$100

*A $100.00 non-refundable fee must accompany this Enrollment Application. Please submit payment via Venmo to @footstepsplayavista or via Zelle to 808-346-0982

Fixed price

$100