Children's Vision Day Care

Pre-Registration Questionnaire
Information of Child
Name*

First NameLast Name
Birth Date*

MonthDayYear
Gender

FemaleMale
Hours of child care required (opening hours are 7:00 am to 7:00 pm)*
Days of the week required*

MondayTuesdayWednesdayThursdayFriday
Do you require before or after school care?

Before schoolAfter school
If yes, what school does your child attend? Do you need them to be dropped off to and picked up from school?
Information of Parent 1
Name*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.
Email Address
example@example.com
Information of Parent 2
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Emergency Contact 1
In the event of an emergency, please contact:
Name*

First NameLast Name
Relationship*
Phone Number
Please enter a valid phone number.
Medical Information
Doctor's Name

First NameLast Name
Doctor's Phone Number
Please enter a valid phone number.
Preferred hospital
Insurance/health coverage
Please list any of the following: Current medications, medication allergies, food allergies, or chronic health concerns.*
Should be Empty:

Information of Child