Child's Information
Child's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Home Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
*
Female
Male
Child Care Attendance Days
Attendance Days- PLEASE ONLY include the days needed and the HOURS NEEDED (do not give a broad range as tuition is based on weekly hours- which is based on this registration form).
*
Monday
Tuesday
Wednesday
Thursday
Friday
From
*
Hour Minutes
AM
PM
AM/PM Option
To
*
Hour Minutes
AM
PM
AM/PM Option
Additional Information regarding Attendance (if you have a flexible schedule, please indicate here)
Parents/Guardian & Emergency Contact Information
Parent 1
*
First Name
Last Name
Email
*
example@example.com
Relationship
*
Mother, Father, etc
Mobile Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Same with the child
Different Address
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent 2
First Name
Last Name
Email
example@example.com
Relationship
Mother, Father, etc.
Mobile Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Same with the child
Different Address
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact 1 (other than parent)
*
First Name
Last Name
Relationship
Home Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Mobile Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact 2 (other than parent)
*
First Name
Last Name
Relationship
Home Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Mobile Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Any other necessary information?
Marital status of parents, medical information, allergies, people who the child cannot be released, etc
Signature- please sign to indicate all information is correct and that you agree to register your child to attend Michelle's Magic School House beginning in August 2025. By signing, you also agree to pay the $75.00 registration fee.
*
Continue
Continue
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