All Smiles Childcare - Initial Request for Registration Form


Pre-registration Information Form

* required fields	Child's Information	Child's Information
*First Name:
*Last Name:
*Gender:	Male Female	Male Female
*Birth Date:
*Address:
*City, Province:
*Postal Code:
*Home Phone #:

Parent / Guardian Information
*Mother's Full Name
*Home Phone #:
*Cell or Business Phone #:
Home or Business Email Address:

*Father's Full Name:
*Home Phone #:
*Cell or Business Phone #:
Home or Business Email Address:

Other Information
*Desired Enrollment Date:
*Program of Interest:
Days of Interest: (check all that apply)*	Monday Tuesday Wednesday Thursday Friday	Monday Tuesday Wednesday Thursday Friday
*Type of Day :	Full Day Half Day	Full Day Half Day
Other Important Information:
How did you hear about us? If other, please specify:
	Security Code: