Enrollment - Teachable Moments Child Development Center Jacksonville, NC

Call Us 910-938-1160

Teachable Moments

Child Development Center

4355-C Gum Branch Road

Jacksonville, NC 28540

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ENROLLMENT

Enrollment

We’d love for you to be a member of the community at Teachable Moments Child Development Center. If you’re interested in our day care center or after school programs, fill out the form below to enroll your child!

Enrollment

Email

Child Name

First

Last

Date of Birth

Enrollment Date

Age

Class

Mother's Information

Name

First

Last

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Email

Home Phone

Mobile Phone

Father's Information

Name

First

Last

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Email

Mobile Phone

Phone

Emergency Contact 1

Name

First

Last

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Phone

Email

Emergency Contact 2

Name

First

Last

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Phone

Email

Child's Physician

Name

First

Last

Phone

Pickup Person 1

Name

First

Last

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Phone

Email

Pickup Person 2 Name

First

Last

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Phone

Email

Child's Information

Child's Allergies

Current Prescribed Medication

Child's Special Medical needs and Conditions

Date of Last Tetanus

Pre-School: Child Care Arrangement for Illnesses

Pre-School: Has Your Child Had The Following?

Measles (Big Red)

Measles (3 Day)

Giardia

Fifth's Disease

Hepatitis B

Chicken Pox

Whooping Cough

Other

Pre-School: Any Serious Illnesses/Hospitalization

Yes

No

Pre-School: Any Physical Disabilities

Yes

No

Specify if Yes

Allergies

By Nature, Is Your Child

Friendly

Shy

Withdrawn

Aggressive

Is your child frightened by any of the following?

First Choice

Dark

Stories

Loud Noise

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Teachable Moments Child Development Center | 4355-C Gum Branch Road | Jacksonville, NC 28540 | Phone: 910-938-1160

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