HCC Pre-Enrollment Childcare Form 2021-22 Email Child's Full Name * Child's Date of Birth * Instructions regarding how parent/guardian may be reached in an emergency * Child's Home Address * City * State * - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Home Telephone Number * Mother/Guardian Full Name * Mother/Guardian Contact Number * Mother/Guardian Email Address * Mother/Guardian Employer Mother/Guardian Employer's address Mother/Guardian Employer's telephone number Father/Guardian Full Name * Father/Guardian Contact Number * Father/Guardian Email Address Father/Guardian Employer Father/Guardian Employer's address Father/Guardian Employer's telephone number Request a Tour Select a time frame and someone will contact you concerning a tour. Date Time 8:00 A.M. - 11:00 P.M. 2:00 P.M. - 5:00 P.M. Person(s) to be contacted in emergency if parent(s)/guardian(s) cannot be reached: Name 1 Name 2 Name 3 Relationship to child 1 Relationship to child 2 Relationship to child 3 Address 1 Address 2 Address 3 Telephone 1 Telephone 2 Telephone 3 Signature (Please type name) * Date * T-shirt Small Medium Large
