Child Care Registration Form

Child Care Registration

BeMyHope Childcare 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 6:00 am to 6:00 pm)*

Full dayHalf-day morningHalf-day afternoonFull day w/therapyHalf-day w/therapyOther
Days of the week required*

MondayTuesdayWednesdayThursdayFriday
Do you require before or after school care?*

Before schoolAfter schoolChildcare onlyChildcare/therapy
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 therapy
Please list any of the following: Current medications, medication allergies, food allergies, or chronic health concerns.*
Signature*

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Does your child have any special needs that need to be met? (Level 1, 2, or 3 Autism)*
Should be Empty:

Child Care Registration

Information of Child

Information of Parent

Medical Information