Visitation Form - Little Heaven Daycare

PLEASE FILL THIS FORM BEFORE ARRIVING TO YOUR APPOINTMENT!

Have you come into close contact (within 6 feet) with someone who has a laboratory confirmed COVID – 19 diagnosis in the past 14 days?
- YES
- NO
2. Do you have any of the following: fever or chills, cough, shortness of breath or difficulty breathing, body aches, headache, new loss of taste or smell, sore throat?
- YES
- NO
Name*
First Last
Email*
Phone*
how old is your child/children:*
when would you like to visit us?*
MM slash DD slash YYYY

We will call you and confirm the visitation date.
Your Address:*
Street Address City State ZIP Code
Child’s Name:*
Day of Birth:*
MM slash DD slash YYYY
Current Childcare Arrangements, and Reason for needing new childcare:
Start day:*
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
How did you hear about us?
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.