Child Care Registration Form

Scholars Academy NJ Child Care Registration

Scholars Academy NJ Child Care Center
Information of Child
Name

First NameLast Name
Birth Date

MonthDayYear
Date
M.I.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender

FemaleMale
Hours of child care required (school hours are 6:30 am to 6:00 pm)

Full dayHalf-day morningHalf-day afternoonOther
Days of the week required

MondayTuesdayWednesdayThursdayFriday
Do you require before or after school care?

Before school $25 DailyAfter school $25 Daily
Information of Parent

Please complete all felids below.
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
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.
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.
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.
Dentist's Name

First NameLast Name
Preferred hospital
Insurance/health coverage ID #
Please list any of the following: Current medications, medication allergies, food allergies, or chronic health concerns.
Upload The following Documents: *Birth Certificate *2 Proof of Address *Immunization / Physical *Parent ID

Cancelof
I give SANJ permission to use any photos, images and video's for all SANJ marketing, promotional and inhouse purposes.
I give SANJ permission to take my scholar on community walks, park play and participate in all outdoor activities within a 5 block radius.
I give SANJ Permission to connect with my primary emergency contact. If unable to connect with primary contact, I give SANJ permission to connect with a secondary emergency contact person. (Please add emergency contact #2 name & contact number here)
Signature

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Scholars Academy NJ Child Care Registration

Information of Child

Information of Parent

Medical Information