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:
MM
/
DD
/
YYYY
Parent/Guardian's Name *
Your answer
Parent/Guardian's Relationship to Child
Parent/Guardian's Occupation
Your answer
Parent/Guardian's Work Schedule (days of week/times each day)
Your answer
Parent/Guardian's Primary Phone Number *
Your answer
Child's Name
Your answer
Date of Birth/Due Date *
MM
/
DD
/
YYYY
Gender *
Primary Address (Street, City, State, Zip Code)
Your answer
Child's Primary Care Physician (Pediatrician)
Your answer
Child's Diagnoses (include medical and behavioral) *
Your answer
Child's Allergies (if applicable)
Your answer
Child's Medications (include daily and "as needed")
Your answer
Special Diet
Your answer
Child's Behavior Challenges (select all that apply) *
Required
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:
Your answer
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 Info@orchidhouse.org or call the center at 502-290-2421.
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service