Please Fill Out The Enrollment Application Below!

Child's Last Name (required)

Child's First Name (required)

Child's Middle Initial (required)

Child's "Called" Name (required)

Child's Birth Date (required)

Address (required)

Address

City (required)

State (required)

Zip Code (required)

Home Phone (required)

Your Email (required)

Mother's Name (required)

Mother's Occupation

Mother's Cell Phone

Father's Name (required)

Father's Occupation

Father's Cell Phone

Nationality

Religious Affiliation

What Church Do You Currently Attend?

What Program are you interested in?

Did you have Older Children Enrolled Here?

If so, When?

How did you hear about Milford Mill Church Child Development Center?

Additional Comments, Special Needs, or Disabilities

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