School Registration

Child's Application for Enrollment
Date Application Completed:
Date of Enrollment:
Student Information
First Name
Last Name
Birth Date

MonthDayYear
Child's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Doctors Name

First NameLast Name
Doctors Phone Number

Area CodePhone Number
Hospital Preference:
I, as the parent/guardian, authorize the center to obtain medical attention for my child in an emergency. Signature of Parent/Guardian
Father's Address
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Home

Area CodePhone Number
Cell

Area CodePhone Number
Work

Area CodePhone Number
Address - Same As Child
Mother's Address
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Home

Area CodePhone Number
Cell

Area CodePhone Number
Work

Area CodePhone Number
Number
Address - Same As Child's
Does your child have any allergies?
If yes please list, including any food or drug allergies.
Does your child have any medical conditions?
Does your child require any medication? If yes, please list these medications.
Do you authorize us to administer the medications listed above?
CONTACTS: Child will be released only to the parents/guardians listed above. The child can also be released to the following individuals, as authorized by the person who signs this application. In the event of an emergency, if the parents/guardians cannot be reached, the facility has permission to contact the following individuals. Please list NAME, RELATIONSHIP, ADDRESS & PHONE NUMBER
Contact #2
Contact #3
I, as the operator, do agree, to provide transportation to an appropriate medical resource in the event if an emergency, In an emergency situation other children in the facility will be supervised by a responsible adult. I will not administer any drug or any medication without specific instructions from the physician or the child's parent, guardian, or full-time custodian. SIGN ELECTRONICALLY
Family religion and/or special preference. Example : Family doesn't celebrate holidays.
Date

MonthDayYear
Should be Empty:

Child's Application for Enrollment

Student Information

Father's Address

Mother's Address