Wise Kids House Parent/Guardian Application

Parent/Guardian

First Parent

Relation to child *

Full Name *

Email *

Phone *

I agree to terms & conditions provided by the company. By providing my email address and phone number, I agree to receive email and text messages from the business. *

I agree

Address *

Work Phone *

Work Address *

Alternative Address

Second Parent

Relation to child *

Full Name *

Email *

Phone *

I agree to terms & conditions provided by the company. By providing my email address and phone number, I agree to receive email and text messages from the business. *

I agree

Address *

Work Address *

Work Phone *

Alternative Address

Enrolment

Date of Request *

When care is needed *

Types of Care *

Full Time (5 Days)

Pets in the provider's home? *

Yes
No
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If no, indicate why.

Special Requirements?

Child 1 Information

Full Name *

DOB *

Gender *

Hours Required *

Currently in care? *

Yes
No
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Immunizations up to date? *

Yes
No
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Toilet trained? *

Yes
No
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Child 2 Information

Full Name

DOB

Gender

Hours Required

Currently in care?

Yes
No
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Immunizations up to date?

Yes
No
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Toilet trained?

Yes
No
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Tuition Agreement

Parent Flat Rate $326.25 / month *

Yes

No

There will be Optional Services, and a Supplemental Fee will be charged monthly (Meals & Specialized classes)

Do you agree with getting those services? *

Yes

No

Living Arrangements

Child lives with *

Mother

Father

Other

Is there a custody agreement? *

Yes
No
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School

Please select one that applies as you expect them to be on your child's start date *

Choose one

Not in school
Attending Kindergarten
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Kindergarten Name:

Referral Source

Where did you hear about Wise Kids House? *

The day home name that you have contacted (if you have)

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