Child Care Registration

Child Care Registration
Fontora Family Childcare
Child's Information
First name*
Last name*
M.I.
Street address*
Street address line 2*
City*
State*
Zip code*
Male or female?*

FemaleMale
Birth Date*

MonthDayYear
Select Child Care location*
Hours of child care required (school hours are 6:00 am to 6:00 pm)*

Full dayHalf-day morningHalf-day afternoonOther
Days of the week required*

MondayTuesdayWednesdayThursdayFriday
Do you require before or after school care?

Before schoolAfter school
Parent's Information
Mother's/Guardian's name*
Mother's Phone number*
Mother's Place of work or work phone*
Mother's Email address*
Father's/Guardian's name*
Father's Phone number*
Father's Place of work or work phone*
Father's Email Address*
Emergency Contact 1
In the event of an emergency, please contact:
First name*
Last name*
Primary phone number*
Secondary phone number*
Emergency Contact 2
In the event of an emergency, please contact:
First name
Last name
Primary phone number
Secondary phone number
Add More contacts or special instructions
Other people authorized to pick up your child from school
First name
Last name
First name
Last name
Medical information
Doctor*
Doctor's phone number*
Dentist*
Dentist's phone number*
Preferred hospital*
Insurance/health coverage*
Please list any of the following: Current medications, medication allergies, food allergies, or chronic health concerns.
Should be Empty: