Child Registration Form
Tell us about your child
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Language Spoken at Home
Child's Home Address
Primary Phone
Please list family members your child lives with, including the names and ages of siblings
Tell us about you
The safety of children in our Daycare is our top priority. Daycare staff will release your child only to the parents and guardians listed—or to the other emergency contacts you authorize below. If you do need to authorize a new pickup person by phone, you may do so—but we will ask you to answer the two security questions you provide here to verify your identity. For your child’s safety, any time a person we do not recognize comes to pick up your child, we will ask for a government-issued photo ID
Parent/Guardian Name
First Name
Last Name
Relationship to child
Parent/Guardian Phone Number
Home Address
Email Address
Employer and Address
ID Number and Type
Work Phone
Emergency Contacts Authorized to Pick up your child (18 yrs or older)
Enter name, relationship , address and contact info
Care Information
Child's Name
First Name
Last Name
Height
Weight
Hair color
Eye color
Our goal is to provide your child excellent education and care. We have a few questions that will help us be better prepared to meet your child’s individual needs. Please indicate if your child receives any of the following supports
Physical Therapy
Speech Therapy
Occupational Therapy
Applied Behavior Analysis
Mobility Device
Communication Device
Feeding Tube
Visual Support
Auditory Support
Would you like your child's Therapists to deliver services at the center?
Yes
No
Is there anything else we need to know about your child to ensure he or she can be well supported by our staff ?
List of current medications:
My Child's Medical Care Provider
Medical Care Provider Name
First Name
Last Name
Practice / Clinic Name
Provider Address
Phone
Preferred Hospital / Clinic
Date of Last Physical Examination
-
Month
-
Day
Year
Date
Dentist Name
First Name
Last Name
Dentist Address
Phone
Health Insurance Provider and Policy Number
My Child's Allergies
Medications
Reactions
Food
Reactions
Respiratory
Reactions
Bee Sting
Reactions
Other
Reactions
Are any of the allergies severe of life-threatening? (if Yes , Please talk to your Center Director About completing and allergy plan.)
Yes
No
Schedules/ Transportation/ Tuition
Child's Name
Child's Date of Birth
Pick-up Information
Name
First Name
Last Name
Phone
Name
First Name
Last Name
Phone
Tuition and Fee Information
My Tuition is :
Weekly
Daily
Tuition
Discount/Adjustment Type
Total Tuition
Submit
Should be Empty: