Child Care Registration Form

Registration Form
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
Hours of child care
Days of the week required
Information of Parent
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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.Format: (000) 000-0000.
Email Address
example@example.com
Place of Work
Other people authorized to pick up child
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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.Format: (000) 000-0000.
Dentist's Name

First NameLast Name
Dentist's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred hospital
Insurance/health coverage
Please list any of the following: Current medications, medication allergies, food allergies, or chronic health concerns.
Should be Empty:

Registration Form