2022 WRAPAROUND SERVICE — Christian Pentecostal Day Care's

2022 Wraparound Service Application

971 Clinton Avenue Location

START DATE

Aftercare will begin on 9.12.2022

MM

DD

YYYY

Child's Information

Child's Name

First Name

Last Name

Child's Date of Birth

MM

DD

YYYY

Child's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name by which child is Most often Called

Prescribed Food Restrictions / Allergies

Mother's Information

Mother's Name

First Name

Last Name

Mother Employed By

Mother Employers Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mother Cell Phone Number

(###)

###

####

Father's Information

Father's Name

First Name

Last Name

Father Employed By

Father Employer's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Father Cell Phone Number

(###)

###

####

EMERGENCY CONTACTS / PICK UP LIST

E1 Name

First Name

Last Name

E1 Relation

E1 Phone

(###)

###

####

E2 Name

First Name

Last Name

E2 Relation

E2 Phone

(###)

###

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TERMS OF ACCEPTANCE AND SIGNATURE

Upon signing this document I indicate my child is in good health and condition to attend aftercare program. I further give Seasons of Learning, Christian Pentecostal Day Care and/or its staff, permission to have my child medically treated in case of any medical emergency while in attendance and/or on a trip.

Name

First Name

Last Name

Email

I, the [applicant, requestor, etc.] for this [type of form], warrant the truthfulness of the information provided in this application.

Method of Payment

Confirmed Program for Parents

Pending Program for Parents

Out-Of-Pocket $70/per week

Other

Electronic Signature

Please type your First and Last Name

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.

2022 Wraparound Service Application

971 Clinton Avenue Location

© 2022 Christian Pentecostal DAY CARE’S

Main location and Mailing Address:

971 Clinton Avenue

Irvington, New Jersey 07111

973-399-7000 ext. 0
CONTACT US