Child: _____________________________ Birth/Due Date: ___________

Father/Guardian Name : ___________________________Avon Employee: Y/ N

Mother/Guardian Name: ___________________________Avon Employee: Y/ N

Home Address: _______________________________________________


Father Work phone_________________ Mother  Work phone__________________

Home  ___________________E-Mail  7am-6pm_____________________@_____

Approximate Drop-off/Pick-up Times: _________________________________

Desired Starting Date: _____________________________

I am interested in enrolling my child in: ________ Full Time _______ Part Time

For PT, please indicate desired days

2 Days:    M    T    W    TH    F     _____can be flexible

3 Days:    M    T    W    TH    F     _____can be flexible

* There is a $75.00 non-refundable application fee per child. This fee ensures that your child is placed on our wait list and does not guarantee future enrollment.
** Please include a check made payable to Little Angels Child Care Center and enclose it with this application.   Mail to: Midland and Peck Avenues Rye, NY 10580

Office Use Only

Date Received:                   Check # :                 Date 18 months:               Date 3 years:

Dates of Contact: