Please fill out the form, a * indicates a required field.
Parent/Guardian's Name: *
Home Address: *
Phone Number: *
Cell Number: *
Child #1 Name, Date of Birth, & Age: *
Child #2 Name, Date of Birth, & Age:
Child #3 Name, Date of Birth, & Age:
Is he/she currently in childcare/preschool? Yes No
If yes, where?
Reason for leaving?
Was he/she previously in childcare/preschool? Yes No
Where did you hear about Little U? *
Days needed at Little U?
5 Days, Full Time: (M-T-W-R-F)
3 Days, Part Time: (M-W-F)
2 Days, Part Time: (T-R) *
What date would you like to start at Little U?
Is your child fully potty trained? Yes No
Any special instructions?