Enrollment

Start Your Child's Journey Today

We're currently enrolling across all age groups. Contact us to learn more and schedule a tour.

Submit Application

Fill out the enrollment form with your child's information.

We Reach Out

Our team contacts you within 1 business day to discuss next steps.

Tour & Welcome

Visit our center, meet the team, and welcome your child to Genesis.

Apply Now

Enrollment Application

Tell us about your child and we'll be in touch to walk you through enrollment.

No application fee to get started
Flexible full-time & part-time schedules
Sibling discounts available
Financial assistance options

Household Information

Home Address *

City

State

Zip Code

Home Telephone Number

Primary Language of Parents

Requested Start Date (Date of Admission)

Program Interested In *

If Other, please describe

Child Information

Parent / Guardian Information

Parent / Guardian 1

Full Name *

Relationship to Child *

Phone Number *

Email Address *

Home Address

If different, address

Employer / Business Location ("Where")

Work Telephone

Cell Phone

Instructions for reaching you during child care hours

Parent / Guardian 2 (optional)

Full Name

Relationship to Child

Phone Number

Email Address

Home Address

If different, address

Employer / Business Location ("Where")

Work Telephone

Cell Phone

Instructions for reaching you during child care hours

Emergency Contact Information

Please list at least two people who may be contacted if parents/guardians cannot be reached.

Emergency Contact 1

Full Name *

Relationship to Child *

Phone Number *

Address

Emergency Contact 2

Full Name *

Relationship to Child *

Phone Number *

Address

Authorized Pickup List

The following people are authorized to pick up your child(ren) from Genesis Steps to Success, in addition to the emergency contacts above. Please let us know at the start of the day when your child will be picked up by one of these individuals.

Name

Relationship

Phone Number

Address

Name

Relationship

Phone Number

Address

Name

Relationship

Phone Number

Address

People NOT authorized to pick up the child(ren)

Transportation Plan & Attendance Schedule

Tell us how your child(ren) will typically arrive and depart, and the days/times you expect them in care.

My child will arrive to the program by

My child will depart the program by

Notes on transportation (who supervises transport or the walk to/from a bus stop, etc.)

Anticipated Days/Time of Attendance

monday

Arrival

Departure

tuesday

Arrival

Departure

wednesday

Arrival

Departure

thursday

Arrival

Departure

friday

Arrival

Departure

saturday

Arrival

Departure

sunday

Arrival

Departure

I will provide copies of any custody agreements, court orders, or restraining orders (if applicable).

Notes

Parental Acknowledgements

I acknowledge that I have received a copy of the provider's parent handbook, including information regarding lead poisoning prevention.

I understand that I may visit this child care program unannounced at any time during the hours that my child is in care.

Parent Communication Preference

Preferred method of communication

Best time to contact parent/guardian

Enrollment Agreement

I understand that enrollment is not complete until all required forms, emergency contact information, health information, and payment arrangements have been submitted and approved.

I agree to follow Genesis Steps to Success policies regarding attendance, pickup, illness, payments, communication, and child safety.

I have read and agree to the enrollment agreement above.

By signing below, you confirm you are this child's parent or legal guardian (or otherwise authorized to enroll them), and that you are at least 18 years old.

Parent / Guardian Name (signature) *

Date *

We'll only use this to respond to you and, if you enroll, to care for your child. See our Privacy Policy for details.