Registration Form

Date of Application (MM/DD/YY)	Start Date (MM/DD/YY)
Program Full Day Half Day
Monday Tuesday Wednesday Thursday Friday
Student's Name
Street Address
City State Zip Code
Sex Male Female	Birth date (MM/DD/YY)

Parent / Guardian Information
Mother's Name	Occupation
Home Phone	Mobile Phone
Email Address
Home Address
City State Zip Code
Company	Work Phone
Work Address
City State Zip Code
Father's Name	Occupation
Home Phone	Mobile Phone
Email Address
Home Address
City State Zip Code
Company	Work Phone
Work Address
City State Zip Code

Pickup Authorization
1. Name	Phone
Relationship
Home Address
City State Zip Code
2. Name	Phone
Relationship
Home Address
City State Zip Code

Emergency Contacts
1. Name	Phone
Relationship
Home Address
City State Zip Code
2. Name	Phone
Relationship
Home Address
City State Zip Code

Name of Person UNAUTHORIZED to pick-up the child
If a non-custodial parent is not included among those persons authorized by the custodial parent to pick up the child, please attach a copy of the appropriate court orders.

Medical Information
Physician Name	Phone
Address
City State Zip Code
Hospital Affiliation
Insurance Company Policy Number

Child's Allergies
Food
Medication
Other

Important information our school should know your child
Who referred you:

I UNDERSTAND THAT I NEED TO PICK UP MY CHILD ON OR BEFORE 6:30PM FOR FULL DAY PROGRAM AND ON OR BEFORE 3:00PM FOR HALF DAY PROGRAM, OTHERWISE THERE WILL BE A LATE FEE CHARGED TO ME BASED ON THE CENTER POLICY.

PARENT SIGNATURE: ______________________________________________________
DATE: ________________________________________

PLEASE NOTIFY OUR DIRECTOR IMMEDIATELY IF ANY OF THE ABOVE INFORMATION CHANGES. THANK YOU!

Print Form

Last Updated: February 9, 2009

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