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ECM - Early Childhood Ministry
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> INFANT & TODDLERS ENROLLMENT
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Child First Name*
Child Middle Name*
Child Last Name*
Child's Gender*
Female
Male
Child Date of Birth*
(mm/dd/yyyy)
Please list any medical issues or allergies your child has:*
Is your child up to date on immunizations?*
You will be required to submit all immunization records prior to enrollment
Yes
No
Are you a returning family?*
Yes
No
Mother First Name*
Mothers Last Name*
Mother Street Address*
Mother City*
Mother Zip Code*
Mother Home Phone*
000-000-0000
Mother Cell Phone*
000-000-0000
Mother Email Address*
Contact Mom First For Emergencies?*
Yes
No
Is Mother Catholic?*
Yes
No
Father First Name*
Father Last Name*
Father Street Address*
Father City*
Father Zip Code*
Father Home Phone*
000-000-0000
Father Cell Phone*
000-000-0000
Father Email Address*
Contact Dad First For Emergencies?*
Yes
No
Is Father Catholic?*
Yes
No
The Child Lives With*
Please Select…
Both Parents
Mother
Father
Other
Has Child Been Baptized Catholic?*
Yes
No
Parent Status*
Please Select…
Married
Separated
Divorced
Other
How did you hear about the SSFC Early Childhood Ministry*
Please Select…
Website
SSFC Parent
Newspaper/Ad
Sign
Other
I am enrolling for the INFANT (6 weeks-12 months) or TODDLER (1 - 3 years):*
Please choose one
Infant - Mon-Fri.
Infant - Mon/Wed/Fri.
Infant - Tues/Thurs.
Toddler - Mon-Fri.
Toddler - Mon/Wed/Fri.
Toddler - Tues/Thurs.
Anticipated Start Date:*
(mm/dd/yyyy)
Please enter the date you would like your child to start:
Enrollment & Supply Fee*
I understand that all fee's must be paid in full in order to hold my spot. Enrollment fee's are non-refundable and due at time of on line registration.
Type Name Here
Fee*
Please select to process payment
Non-Refundable Enrollment Fee - $125 & Supply Fee $75 ($200 Total)
Please send a confirmation email to the address below*:
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