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Gloria Ainsworth Child Care and Learning Center

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Enrollment Form

*Todays Date

*Childs Name

*Age

*Birthday

Month

Day

Year

Special Needs/Allergies if any:

*Date Spot Desired:

*Payment

DHS

Private

Chickasaw

*Parent/Guardian Name

*Relationship to Child

*Cell Phone

*Work Phone

If you do not have a work phone number, please re-enter cell phone.

Home Phone

*Place of Employment

*Has the Child Attended Daycare Before?

If so, Where?

Vital Information

Sibling(s) Information

Gloria Ainsworth Child Care & Learning Center

502 G St NE

Ardmore, OK 73401

580-226-3321

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