Full Pay Application

Child Information

Name

If you are applying before the birth of your child and do not know your child’s name yet, please write as: “Last Name, Baby.” Also, please follow up when your child is born with the exact birth date, gender and name.

First Name

Last Name

Date of Birth

YYYY

Gender

Languages Spoken at Home

Race

Select all that apply

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

Caucasian

Hispanic or Latino

Does Child have Special Needs?

If Other, Please Explain:

Parent A

Name

First Name

Last Name

Relationship to Child

Contact Language

Physical Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Phone Number

(###)

###

####

Parent A Gross Monthly Income

Do you live with the other parent?

Parent B

Name

First Name

Last Name

Contact Language

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Phone Number

(###)

###

####

Parent B Gross Monthly Income

Do you have another child currently enrolled at HFDH?

Have you submitted an application in the past for another child?

How did you learn about HFDH?

Please keep your contact information up to date with HFDH. Certain changes may affect your eligibility, and you may lose a potential spot if we are unable to contact you. Signing up for HFDH’s waitlist does not guarantee enrollment in our Toddler, and Preschool program. HFDH does not offer part-time childcare.

I affirm to the best of my knowledge and belief, that the above information is accurate as stated. I understand that it is my responsibility to keep my information up to date including changes in income, contact information and any other factors which may impact my application. Furthermore, I understand that to keep my application active I must respond to an annual waitlist confirmation.

Print Name:

Date

YYYY