Child Care Registration Form

Before School

After School

Approximate time of student pick up on days selected?
Who will typically be picking up the student on days selected?
Other information for After School Child Care
Parent/Guardian Information
Father/Guardian Name
Father Phone
Format: (000) 000-0000.
Father Email Address
example@example.com
Mother/Guardian Name
Mother Phone
Format: (000) 000-0000.
Mother Email Address
example@example.com
Emergency Contact Information

Please list at least one Emergency Contact person.
Emergency Contact Name (1)
Relationship to Child (1)
Emergency Contact Phone Number (1)
Format: (000) 000-0000.
Emergency Contact Name (2)
Relationship to Child (2)
Emergency Contact Phone Number (2)
Format: (000) 000-0000.
Medical Information

Please list anything that Child Care should be made aware of here.
Does the student have a medical condition, allergy action plan, or restriction? If yes, please explain.
Name of Parent/Guardian Completing Form
Date

MonthDayYear
Date
For placement in the Child Care Program, complete and submit this form, along with a $30.00 family registration fee.
Should be Empty:

Student Information