HTML Preview Family Registration Card page number 1.
FAMILY REGISTRATION FORM SHEET 1 OF 3
Parent/Guardian Information
Registration Date:
Mother/Guardian First Name:
M.I. Last Name:
Address:
Occupation:
Home Phone: ( )
Employed By:
Office Phone: ( )
Work Address:
Work Hours: Cell Phone: ( )
[ ] Custodial Parent (If married, mark both parents) Mother’s SS#:
Email:
Driver’s License #:
Preferred PIN number for checking in/out (4 digits, numbers only) 1
st
choice __ __ __ __ 2
nd
Choice __ __ __ __
Marital Status:[ ] Married [ ] Single [ ] Divorced [ ] Separated [ ] Widowed [ ] Other_____________________
Father/Guardian First Name:
M.I. Last Name:
Address:
Occupation:
Home Phone: ( )
Employed By:
Office Phone: ( )
Work Address:
Work Hours: Cell Phone: ( )
[ ] Custodial Parent (If married, mark both parents) Father’s SS#:
Email:
Driver’s License #:
Preferred PIN number for checking in/out (4 digits, numbers only) 1
st
choice __ __ __ __ 2
nd
Choice __ __ __ __
Marital Status:[ ] Married [ ] Single [ ] Divorced [ ] Separated [ ] Widowed [ ] Other_____________________
Child Information
1
st
Child First Name: M.I. Last Name:
Name child prefers to be called: Grade/Class:
Child’s Address:
Gender: [ ] Male [ ] Female Date of Birth:
Child’s S.S. #:
List any existing medical conditions, medication and/or special attention your child may require?
Allergies:
Pediatrician’s Name:
Phone: ( )
Address:
Photographs: May we take and maintain a photo of your child for security purposes? [ ] Yes [ ] No