2022-2023 Crawfords Comfort Zone Registration

Enrollment Application

Fill out the form carefully for registration
Student Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Grade Level: (for current school year)
Age:
Hobbies:
Please list hobbies of your child including but not limited to at home hobbies.
Phone Number
Parent/Guardian Information

Please enter parents/guardian information below
Mother/Guardian Name
First Name
Last Name
Home Address
Physical Address
City, State, Zip
Mailing Address
City, State, Zip
Employer
Work Address
Home Number
Work Number
Cell Number
Email Address
Father/Guardian Name
First Name
Last Name
Home Address
Physical Address
City, State, Zip
Mailing Address
City, State, Zip
Employer
Work Address
Home Number
Work Number
Cell Number
Email Address
Authorized Release & Emergency Information

Your child will only be released to the mother, father, or guardians listed above in addition yo the authorized persons listed below. Legal authorities will be contacted if your child is left at the center one hour after the center closing hours. Please indicate if the persons listed below should be used as on emergency contact

Type a question

Person(s) Not Authorized to Pick Child Up:
Medical Information
Child's Pediatrician
Address
Phone Number
Child Has Insurance Coverage

YesNo
Insurance Information
Company Name
Hospital Preference
My Child has:

an allergy to medicine, food, plant, animal, or insecta condition or fear that may require special care, procedures, services, medication or dietnone of the above
If you answer yes, please explain:
Program Selection

Please select the program you would like for your child to attend
Which program best suits your child?
Other Information
How did you hear about us?
Parent Referral Name
SIGNATURES
*
By signing below I understand that Crawford's Comfort Zone is an exempt licensening company and agree to all terms and rules of CCZ.

Yes, I agreeNo, I do not agreeNeed more information
Signature of Parent/ Guardian
Date
Signature

Clear
Signature of Director
Date
Signature

Clear
All Fees are Non-Refundable