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?

Birth Date

Select Child Care location

Hours of child care required (school hours are 6:00 am to 6:00 pm)

Other

Days of the week required

Do you require before or after school care?

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.