Child Care Registration

HOLIDAY CARE
LIFE CHANGERS CHRISTIAN ACADEMY

4635 N US HIGHWAY 1 MELBOURNE FL 32935

O: 321-333-5168

F: 321-574-6615
Child's Information
First name
Last name
M.I.
Street address
Street address line 2
City
State
Zip code
FemaleMale
Full dayHalf-day morningHalf-day afternoonOther
MondayTuesdayWednesdayThursdayFriday
Before schoolAfter schoolHoliday careN/a
Parent's Information
Parent's/Guardian's name
Phone number
Place of work
Email address
Emergency Contact 1
In the event of an emergency, please contact:
First name
Last name
Primary phone number
Secondary phone number
Emergency Contact 2
In the event of an emergency, please contact:
First name
Last name
Primary phone number
Secondary phone number
Other people authorized to pick up your child from school
First name
Last name
First name
Last name
Medical information
Doctor
Doctor's phone number
Dentist
Dentist's phone number
Preferred hospital
Insurance/health coverage
Please list any of the following: Current medications, medication allergies, food allergies, or chronic health concerns.
Should be Empty: