Child Care Registration Form

Child Information
Child Name*

First NameLast Name
M.I.
Date of Birth*

MonthDayYear
Date
FemaleMale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Full-time (Mon-Fri)Single Day Service (as needed)
MondayTuesdayWednesdayThursdayFridayHolidaysNot Required
Early Drop-Off (6am-7am)After Care Hours (3pm-6pm)Not Required
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
- FemaleMale
- Full-time (Mon-Fri)Single Day Service (as needed)
- MondayTuesdayWednesdayThursdayFridayHolidaysNot Required
- Early Drop-Off (6am-7am)After Care Hours (3pm-6pm)Not Required
- 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