Mama Daycare Enrollment Form (2025-2026)
29637 Silver Summit St., Menifee, CA 92584 
Phone: (951) 466-8741  
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Child Information
 *
  • Child's Full Name
  • Date of Birth
  • Age
Gender *
Required
Parent/Guardian Information 1
 *
  • Full Name
  • Relationship to Child 
  • Phone Number
  • Email
  • Address
Parent/Guardian Information 2 (Optional)
 *
  • Full Name
  • Relationship to Child 
  • Phone Number
  • Email
  • Address
Emergency Contact Information (other than parent/guardian)
 *
  • Full Name
  • Relationship to Child 
  • Phone Number
  • Address
Authorized Pick-Up Persons
 *
  1. Name and Phone
  2. Name and Phone
  3. Name and Phone
Health Information
 *
  • Pediatrician’s Name
  • Phone Number
*
Does your child have any allergies?
Required
*
If yes, please specify: 
*
Any medical conditions or special needs?
Required
*
If yes, please specify: 
*
Immunizations up to date?
Required
Program Selection
 *
Required
*
Requested Start Date:
*
Days of Care Needed:
Required
Developmental Information
 *
Does your child have any special needs, dietary restrictions, or behavior concerns?
Required
*
If yes, please specify:
Required
Permission & Consent
 *
Emergency Medical Treatment: In the event of an emergency, I give permission for Mama Daycare staff to seek necessary medical treatment for my child.
Required
*
Photo/Video Release: I consent to my child’s photo/video being taken for daycare activities and internal purposes (not for public use).
Required
Enrollment Agreement
 *
By signing below, I understand that the information provided is accurate. I agree to comply with all Mama Daycare policies and procedures, including payment and attendance requirements.

Parent/Guardian Signature and Date:
Submit
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