Parent and Provider Contract/Enrollment Application – HeadStart

Parent and Provider Contract/Enrollment Application

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Date of Application

Date of Start

Child's name

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Age

Sex

Birth Date

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Home Address

City/Zip

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Parent Name 1

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Home Address

City/Zip

Email

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Mobile

Home Phone

Work

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Parent Name 2

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Home Address

City/Zip

Email

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Mobile

Home Phone

Work

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1. Daycare Payments can be made by cash or check made payable to:

2. We are open Monday through Friday (7:30am to 5:30pm). I/We will be need childcare for our child normally beginning a

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At

Ending at

4. Check One...

Note: To figure out the monthly payment you do the following (weekly amount × 52 weeks = 12 months).

5. Our weekly or monthly selected tuition price is (refer to price sheet)