Little Rascals - New Enrollment Inquiry Form

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Enrollment Inquiry Form for new customers

Email *

Parent's Name

Parent's Phone #

When do you plan to enroll *

ASAP

With in week

Within few weeks

Next few months

Other:

Need full time or part time Care *

Full time

Part time, (Please specify how many days/week, days of the week in comments below)

Special / specific needs, please provide details in comments below

Before School drop off only - Please specify school name in comments below

After School Pickup only - Please specify school name in comments below

Before & After School drop off and pickup - Please specify school name in comments below

Required

Previously Enrolled in a daycare? If yes please provide information. Special needs ? Please specify

Student 1: Name - Add School name if Pickup and Drop is needed *

Student 1 Date of Birth *

YYYY

Student 2: Name, Add School name if Pickup and Drop is needed

Student 2 Date of Birth

YYYY

Student 3: Name, Add School name if Pickup and Drop is needed

Student 3 Date of Birth

YYYY

How did you hear about

Google Search

Facebook

Word of Mouth

Repeat Customer

Drive by

Other:

Do you have NCI, if not would you like to know more about it. This is Texas a Workforce Childcare Assistance program. You can see details here or in your email after the form is submitted https://tinyurl.com/r3lsrme

I already have NCI / Workforce Childcare Assistance

I would like to know more about NCI / Childcare Assistance

I don't qualify for NCI

Yes

Other:

Clear selection

Comments, Questions, Remarks *

A copy of your responses will be emailed to the address you provided.

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