ReVillage Enrollment Form
Please read the ReVillage Handbook before completing this enrollment form. You can read the handbook here:
Once we have received your completed enrollment form, our coordinator will be in contact within 3-5 business days.
Haga clic en el siguiente enlace para nuestro formulario de inscripción en español:
Your First & Last Name
The following questions will help us get to know you and your family. If you'd rather have a phone conversation with a staff person, please just indicate that in the answer boxes.
I will fill out the questions.
Please call me with the number listed below.
Child's Full Name
Child's Nickname (or name Child responds to)
Monday Full Day
Tuesday Full Day
Wednesday Full Day
Thursday Full Day
Friday Full Day
Monday Half Day
Tuesday Half Day
Wednesday Half Day
Thursday Half Day
Friday Half Day
Child Lives With
Emergency Contact Name and Relationship to Child
Emergency Contact Phone Number
Who is authorized to pick you child up from the center?
Are you planning to utilize assistance through Baby Promise?
I'm not familiar with Baby Promise
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