Child Care Registration Form

Child Care Registration

A Change In The Game
Information of Child
Name

First NameLast Name
M.I.
Birth Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender

FemaleMale
Hours of child care required (school hours are 7:00 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 schoolAfter school
Information of Parent
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
Dentist'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:

Child Care Registration