Wonderland Enrollment Form

Wonderland Enrollment Form
Our director will be in contact with you in the next 24 hours.
What is your name?
This question is required
What is your email address?
Please enter a valid email
What is your address?
Street*
City/Suburb
State*
Zip/Post Code*
Country*
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What is your primary phone number?
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Is there an additional parent or guardian you would like to add to the file?
Yes
No
Please choose an answer

What is your desired start date?
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Which location?
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Please provide the name of an emergency contact.
This question is required
What is their phone number?
This question is required
What is their address?
Street*
City/Suburb
State*
Zip/Post Code*
Country*
This question is required
What is their relationship to you or the child?
This question is required
Would you like to add another emergency contact?
Yes
No
Please choose an answer



Are you currently employed?
Yes
No
Please choose an answer


What is your child's name?
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What is your child's gender?
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How old is your child?
Please enter a number greater than or equal to 1
What is your child's birthdate?
/
/
Please enter a valid date
Does your child have any known allergies?
Yes
No
Please choose an answer
If yes, please explain your child's allergies.
This question is required
Does your child have any illnesses or medical conditions?
Asthma
Diabetes
Seizures
Heart Problems
Hearing Impairment
Visual Impairment
Physical Impairment
Developmental Delays
Behavioral or Emotional Problems
Other
This question is required
If yes, please explain your child's medical condition.
This question is required
Who is your childs current medical provider?
What is the providers phone number?
Do you want to add another child?
Yes
No
Please choose an answer




Is there any other information you would like to provide?
Yes
No
Please choose an answer


Please provide your signature:
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Date of application:
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Submit