Child Care Registration

Name

First NameLast Name
Child information

6 weeks-12 months ($170/week or $34/day) 13 months and up ( $165/week or $33/day) After school ($10/ day) week during school year.
Birth Date

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender
Hours of child care required (school hours are 7:00 am to 5:00 pm)

Other
Days of the week required
Do you require before or after school care?
Information of Parent
EMERGENCY CONTACT Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Place of Work
Emergency Contact 1
In the event of an emergency, please contact:
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Place of Work
Other people authorized to pick up child from school
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Place of Work
Medical Information
Doctor's Name

First NameLast Name
Doctor's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Dentist's Name

First NameLast Name
Dentist's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred hospital
Insurance/health coverage
Please list any allergies to food or medications or any other information you would like for us to know.
Should be Empty:

Child information