Children's Program Registration 2024-2025

LCOS-ESL Childcare Registration Form 2024-2025
Parent Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
When would you like child care?

AM (morning)PM (afternoon)
Child's Name

First NameLast Name
My child's age is:
My child's birthday is:
My child's school is"
My child is in grade:
Does your child have any medical concerns/allergies that we should know about?

YesNo
If your child does have medical concerns/ allergies, please list them.
Does your child speak English?

YesNo
Is your child in an ESL program at school?

YesNo
This person may pick up my child from the Children's Program.
Relationship: ________________________________________
Please remember:

A child's immunizations must be up to date.

If your child is sick, she/he may not be dropped off in the Children's Program,

You should bring all needed supplies for your child, such as diapers, formula, wipes etc.
Signature

Clear
Date:
Should be Empty: