United Child Care Center Register Your Child For Nanny Service Only

Please fill out the form and then click on the submit button.

1. Please fill in all the fields, so we can register your child.
2. If you have 2 or more children to register, please register them one by one separately
3. The asterisk sign (*) means required.
4. Input N/A if the question does not apply to your case.

I. Child's Information:

1.Child's Full Name (First Name, Last Name)(*)

2. Child's Birthdate (month, day, year)(*)

3. Child's Gender: (Male or Female) (*)

II. Parents' Information:

1. Father's Full Name (*)

2. Father's Email: (*)

3. Mother's Full Name: (*)

4. Mother's Email: (*)

5. Street Address1: (Number and Street)(*)

6. Street Address2: (Building, Floor, Suite, Room, PO Box, etc.)(*)

7. City: (*)

8. State/Province: (*)

9. Zip Code: (*)

10. Country: (*)

11. Emergency Phone Number at Work: xxx-xxx-xxxx(*)

12. Emergency Phone Number at Home:xxx-xxx-xxxx(*)

12. Emergency Email:(*)

III. Payment Method:(required)

1. Choose A Rate:
a. Daily Rate = $160 for 8 hrs-day.
b. Weekly Rate: $800 for 5 days-week.
c. Monthly Rate: $3,000 a month.

2. Choose One Type:
a. Cash
b. Money Order

IV. Child Health Information:

1.Input Comments: Is the child allergic to some food or objects or animals? If yes, please specify.

2. Input Comments: Is the child taking prescribed medication for some illness? If yes, give instructions on when and how to give medicine.
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