Admission – littlehavenchildcare.com

Child Information

Tell us about the child being enrolled

First Name

Middle Name

Last Name

Date of birth

Age Group

Care Type

Gender

Requested Care Start Date

Allergies / Medical Conditions (list any known allergies, conditions, or dietary restrictions

Special Needs / Accommodations (describe any special needs, disabilities, or accommodations needed)

Parent / Guardian Information

Primary Guardian

Parent/Guardian First Name

Parent/Guardian Last Name

Relationship to Child

Phone

Email Address

Office Alternative Phone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Who Has Permission To Pick Up Your Child?

Please provide at least 2 contacts (other than parents/guardians)

First Name

Last Name

Relationship to Child

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Number

Name

Relationship to Child

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone

Health & Medical Records

All documents must be submitted before your child's first day

Child's Pediatrician / Physician Name

Pediatrician Phone #

Date of last physical exam

⚠️ Physical exam must be dated no more than 6 months before the admission date.Physical exam on file or will be submitted before first dayProof of all immunizations provided or will be providedTB test result on file or will be providedLead screening result on file or will be provided

Physical Exam / Immunization Records

No file chosen

TB Test / Lead Screening Results

No file chosen

Fees & Payment Agreement

Please review and agree to the fee structure below

Fees & Payment Agreement

Service	Rate
Weekly Rate — Child (Age 2+)	$375 / week
Weekly Rate — Infant	$399 / week
Hourly Rate	$20 / hour
Late / Early Pickup Fee	$2.00 / minute (cell phone time)
Late Payment Fee	$10.00 / day after due date
Returned Check Fee	$40.00 + additional costs
Enrollment Deposit (2 weeks)	Non-refundable if care does not start

Please review and agree to the fee structure aboveI understand and agree to the fee structure listed aboveI understand a 2-week written termination notice is requiredI understand the enrollment deposit is non-refundable if care does not begin on the agreed date

Policy Acknowledgment & Signature

By submitting, you confirm you have read and agreed to the Little Haven Parent Handbook

CheckboxI have read and understood the complete Parent HandbookI agree to all policies as outlined in the handbookI Give Permission That My Child May Be Given First Aid / Emergency Medical TreatmentI understand that changes to my contact information must be provided in writing

Type your full name as signature

Date of Submission

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Apply For Admission

Child Information

Tell us about the child being enrolled

Parent / Guardian Information

Primary Guardian

Who Has Permission To Pick Up Your Child?

Please provide at least 2 contacts (other than parents/guardians)

Health & Medical Records

All documents must be submitted before your child's first day

Fees & Payment Agreement

Please review and agree to the fee structure below

Policy Acknowledgment & Signature

By submitting, you confirm you have read and agreed to the Little Haven Parent Handbook

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