Child Information(Required) Enter the child's legal name.
First Middle Initial Last
Date of Birth(Required) Enter the child's date of birth.
Home Address(Required) Enter the physical address where the child lives.
Mother or Legal Guardian's Information(Required) Enter the mother or legal guardian's name.
First Middle Initial Last
Home Address(Required) Enter the mother or legal guardian's home address.
Email(Required) Enter the mother or legal guardian's email address.
Employer's Address(Required) Enter the mother or legal guardian's employer's physical address.
Father or Additional Legal Guardian's Information Enter the father or additional legal guardian's name.
First Middle Initial Last
Home Address Enter the father or additional legal guardian's home address.
Email Enter the father or additional legal guardian's email address.
Employer's Address Enter the father or additional legal guardian's employer's physical address.
Custody: Child lives with:(Required) Select who the child lives with.
Mother - Name entered above Father - Name entered above Legal Guardian - Name entered above
Does a court order exist restricting contact with anyone(Required) Select whether a court has forbidden someone from having contact with the child. If you've answered "Yes", you must provide Little Duckling a copy of the court order detailing the restricted contact.
No Yes
Emergency Contact Enter the name of someone who may be contacted in the event of an emergency when the parent or legal guardian cannot be reached.
First Last
Pick Up Authorization 1 To ensure the safety of your child, please enter the name of an adult to whom your child may be released. Photo ID will be required to verify identity upon pick up.
First Last
Pick Up Authorization 2 To ensure the safety of your child, please enter the name of an adult to whom your child may be released. Photo ID will be required to verify identity upon pick up.
First Last
Pick Up Authorization 3 To ensure the safety of your child, please enter the name of an adult to whom your child may be released. Photo ID will be required to verify identity upon pick up.
First Last
Pick Up Authorization Consent(Required) I authorize the above listed individuals to pick up my child.
I understand by completing this authorization, that if I need to update the above listed individuals, I must do so in writing and submit the request to Little Duckling before the updated individual is allowed to pick up.
Emergency Medical Contact Name(Required) In the event of a serious accident or injury, we will immediately call 911 and administer First Aid or CPR. We will then call the parent/guardian immediately. If we are unable to reach a parent or guardian, we will contact the designated Emergency Contact Person.
First Name Last Name
Emergency Medical Consent(Required) I hereby authorize Little Duckling to administer First Aid, CPR, or emergency medical care to my child in the case of an emergency, severe injury, or acute illness. I understand 911 will be called immediately. I understand I will be contacted immediately.
I authorize Little Duckling to administer emergency medical care.
Physician's Address Dentist's Address Medical Information(Required) Does your child have any of the following medical conditions? A medical condition does not exclude your child from care. Disclosing important medical information allows Little Duckling to provide the best level of care your child requires. If you indicate your child has a medical need, you must provide a doctor's statement with signature to Little Duckling detailing any special accommodations, medications, or instructions that are required to care for your child.
Anything we need to know or concerns you may have? Please provide any other information you feel will help Little Duckling provide care for your child or any concerns you may have related to your child's medical or developmental needs.
Photographic & Video Release(Required) Little Duckling Early Learning Christian Academy has continuous interior and exterior video surveillance of its parking area, entryways, interior hallways, and each classroom. This surveillance is used for the protection and safety of its facility, staff members, visitors, students, and families on site. Video recorded through our surveillance system will not be shared with any unauthorized individual unless required through court order.
Urgent Email Notification(Required) In the event of severe weather closings, special events, center closing reminders, or emergencies, Little Duckling wants to notify parents as soon as possible. Please provide an email address to receive messages.
Urgent Contact Acknowledgement(Required) Little Duckling will contact you via phone, text, or email for urgent updates or notifications. You must keep valid contact information on file at all times.
I understand Little Duckling will contact me by phone, text, and email for urgent notifications and it is my responsibility to keep valid contact information on file at all time
Additional Documents Acknowlegement(Required) There are additional documents required to complete your child's enrollment process with Little Duckling Early Learning Christian Academy. Little Duckling will provide you with those items after receiving your online enrollment application.
I understand there are additional documents that must be submitted to complete my child's enrollment application with Little Duckling Early Learning Christian Academy. I agree to submit all required items.
Upload Required Documents (Birth Certificate)(Required) Please provide a copy of your child's birth certificate.
Upload Required Documents (Immunization Record)(Required) Please provide a copy of your child's CURRENT immunization record.
Upload Required Documents (Physical)(Required) Please provide a copy of your child's most recent physical dated within 1 year and signed by a physician.