Re-Application Form

Northside Learning Center Child's Annual Re-Application
Today's date

MonthDayYear
Date
Desired date of admission

MonthDayYear
Date
Full name of Child
What does your child like to be called
Birth date of child

MonthDayYear
Date
Social Security Number
Mother's name
Address
Home Phone
Cell Phone
Work Phone
Pager Number
Employed at
Typical work hours
Email address
example@example.com
Social Security Number (last 4 digits) XXX-XX- Father's name
Social Security Number (last 4 digits)
Father's name
Address
Home Phone
Cell Phone
Work Phone
Pager number
Employed at
Typical work hours
Email address
example@example.com
Social Security Number (last 4 digits) XXX-XX-
Social Security Number (last 4 digits)
Person authorized to act for parents in an emergency
Emergency Contact's Name

First NameLast Name
Emergency Contact's Address
Emergency Contact's Home Phone
Emergency Contact's Cell Phone
Emergency Contact's Work Phone
Emergency Contact's Pager number
Employed at
Transportation Plan
To insure the safety of your child, please list all adults to whom your child may be released or who are authorized to provide transportation for your child.
Insurance Information
Please list your insurance information. We have secondary insurance coverage for your child in case of an emergency. Our provider requires that we have listed the company of the child's primary coverage.
Subscriber's name
Company Policy Phone number
Company
Policy ID number
Physician Information
Phone number of Physician
Name of physician
Other Children in Family
Please List Name / Birthdate / School
What is the best way to contact you in case of an emergency (text, call or email)?
Please list any family changes that have been made in the past year (death, divorce, remarriage, move, etc.) This can include anything that may possibly affect your child's behavior.
Please sign below if you give permission to NLC to put your child's picture on our facebook page. The page is open to the general public to view.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Northside Learning Center Child's Annual Re-Application

Person authorized to act for parents in an emergency

Transportation Plan

Insurance Information

Physician Information