Marty's Orchid House - Referral Form
Please fill out the following information to add your child to our WaitList. We accept children between ages 18 months and 6 years, or through the start of Kindergarten with Autism, behavior/emotional challenges, and health issues. Marty's Orchid House offers pediatric nurse care for health issues, low-ratio classrooms with individualized curriculum, and a high-quality meal program. We partner with TheraPlace and Clinical Behavior Analysis to provide therapy services in our building. At this time we offer full-time, Monday-Friday enrollment only with daily schedules built around your child's needs and your work schedule. Please call 502-290-2421 with any additional questions.
Email address *
Preferred Start Date:
Parent/Guardian's Name *
Parent/Guardian's Relationship to Child
Clear selection
Parent/Guardian's Occupation
Parent/Guardian's Work Schedule (days of week/times each day)
Parent/Guardian's Primary Phone Number *
Child's Name
Date of Birth/Due Date *
Gender *
Primary Address (Street, City, State, Zip Code)
Child's Primary Care Physician (Pediatrician)
Child's Diagnoses (include medical and behavioral) *
Child's Allergies (if applicable)
Child's Medications (include daily and "as needed")
Special Diet
Child's Behavior Challenges (select all that apply) *
Has your child been dismissed from another child-care program? *
Child's Primary Insurance Provider *
Please describe your primary reason for your interest in this program:
Will enrollment for your child allow you to work outside of the home and/or maintain employment? *
Marty's Orchid House is located at 703 S. 31st St. Louisville, KY 40211 in the Parkland neighborhood. Will you be able to transport your child to/from the center each day? *
Thank you for your interest! Someone will contact you shortly!
We appreciate your interest in our unique program! Someone from our team will contact you to verify your place on our WaitList. You are under no obligation to enroll your child in our program should you find a suitable program or change your mind at any time. Please don't hesitate to contact us for any further questions at or call the center at 502-290-2421.
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy