Portage, MI Enrollment Form

Please fill out the information below to begin the enrollment process

Enrolling multiple children?

Enroll Multiple Children

Parent Name

First Name

Last Name

Additional Parent Name

First Name

Last Name

Child's Name

First Name

Last Name

Child's Birthdate

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mobile Phone

(###)

###

####

Work Phone

(###)

###

####

Home Phone

(###)

###

####

Email

Desired Start Date

MM

DD

YYYY

Age of Child When Starting

Type of Care Needed

Additional Comments or Concerns

*Note: Each Enrollment Application requires a $95 registration fee to reserve your child’s placement with our center

Portage, MI Enrollment Form

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