Child Care Registration

Child Care Registration
Our Pride Child Care Services
Additional documents for registration Bring this registration form and the following documentation to the office. • Original Certified Birth Certificate• Original Social Security Card• Current Immunization Form• Current Proofs of Residence (ex. power, water or gas bill)• Other
Child Information
Name

First NameLast Name
M.I.
Birth Date

MonthDayYear
Gender
Ethnicity
Email Address
Entry Year
Grade
Current Residence Information
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Primary Residence Information (if different from above)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Residence Information (if different from above)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact 1
Name

First NameLast Name
Phone Number

Area CodePhone Number
Emergency Contact 2
Name

First NameLast Name
Phone Number

Area CodePhone Number
Physician and Medical Information
Name

First NameLast Name
Phone Number

Area CodePhone Number
Preferred Hospital
Insurance/Health Coverage (Company)
Please list any of the following: Current medications, Medication allergies, Food allergies, Chronic health concerns.
Notes
Please inform the office of any other vital information you think they may need to know in the event of an emergency. Thank you.