Child Care Registration Form

Child Information
Child Name

First NameLast Name
M.I.
Date of Birth

MonthDayYear
Date
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Hours of Care Required (Standard Hours of Operations are 7:00 am to 3:00 pm)
If "Single Day Service" is needed, please select the day(s) of the week you will require care
Do you require before or after school care?
Parent/Guardian Information
Parent/Guardian 1
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Parent/Guardian 2
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Emergency Contact Information
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
Emergency Contact 2
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
Other people authorized to pick up child from daycare
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Medical Information
Pediatrician's Name

First NameLast Name
Pediatrician's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred hospital Name
Insurance/health coverage
Please list any of the following: Current medications, medication allergies, food allergies, or chronic health concerns.
If not applicable enter N/A
- Child Name
  
  First NameLast Name
- M.I.
- Date of Birth
  
  MonthDayYear
  Date
- Gender
- Hours of Care Required (Standard Hours of Operations are 7:00 am to 3:00 pm)
- If "Single Day Service" is needed, please select the day(s) of the week you will require care
- Do you require before or after school care?
- Medical Information
- Pediatrician's Name
  
  First NameLast Name
- Pediatrician's Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Preferred hospital Name
- Insurance/health coverage
- Please list any of the following: Current medications, medication allergies, food allergies, or chronic health concerns.
  If not applicable enter N/A
Should be Empty:

Child Information

Parent/Guardian Information

Emergency Contact Information

Medical Information

Medical Information