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A relaxed, supportive, nurturing experience for children who have worked hard all day

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2025-2026 Enrollment Form

2025-2026 Childcare Registration Form

Child Name*

Child Name 2 (If registering 2 children)

Parent 1 Information

Name*

Parent 1 Address

Country/Region*

Address*

City*

Zip / Postal code*

Work Name & Address

Cell Phone*

Email*

Parent 2 Information

Name

Multi-line address

Country/Region

Address

City

Zip / Postal code

Cell Phone

Email

Authorized Pickup/Emergency Contacts

Contact 1

Name*

Relationship*

Phone*

Contact 2

Name*

Relationship*

Phone*

Contact 3

Name*

Relationship*

Phone*

Medical Info

Doctor's Name*

Doctor's Phone*

Hospital Preference*

Insurance Name & Policy Number*

School Information

Which Program is Your Child Enrolled in?

JBBP

Second Community

Child 1

Grade*

Teacher*

Birthdate*

Month

Day

Year

Allergies

Child 2

Grade

Teacher

Birthdate

Month

Day

Year

Allergies

Childcare Hours

Monday

Morning

Afternoon

Monday Dismissal Information

Tuesday

Morning

Afternoon

Tuesday Dismissal Information

Wednesday

Morning

Afternoon

Wednesday Dismissal Information

Thursday

Morning

Afternoon

Thursday Dismissal Information

Friday

Morning

Afternoon

Friday Dismissal Information

Call: 415-699-4170

Email: clarendonbac@gmail.com

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