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HTML Preview Printable Childcare Registration Form page number 1.
1
10.9.2.6 Child Care Registration Form
Rev. 04/12
Child Care Reg
istration Form
Date child ente
red care
Date child left ca
re
C
hild’s
nam
e
L
ast
First
Middle
Name (Nick
name) u
sed
Birthdate
Street address
C
ity
Zip code
Child’s parent
/guardian nam
e
home phone #
( ) -
cell phone#
( ) -
alternative phone
#
( ) -
Street address
C
ity
Zip code
Address where y
ou can be reache
d while child i
s in care
C
ity
Zip code
Child’s parent
/guardian nam
e
home phone #
( ) -
cell phone#
( ) -
alternative phone
#
( ) -
Street address
City
Zip code
Address where y
ou can be reache
d while child i
s in care
City
Zip code
Other than y
ou, who else has pe
rmission to pick
up your child
?
Name
Address
Telephone num
ber
Name:
Relationship:
Home: ( ) -
Cell: ( ) -
Alternative
:
(
) -
Name:
Relationship:
Home
:
( )
-
Cell
:
(
) -
Alternative
:
(
) -
Name:
Relationship:
Home
:
( )
-
Cell
:
(
) -
Alternative
:
(
) -
Name:
Relationship:
Home
:
( )
-
Cell
:
(
) -
Alternative
:
(
) -
In case of an em
ergency
, I give perm
ission for any of t
he following ind
ividuals to
be contacted
and my
child m
ay be
released to any
of them.
Par
ent/Guardian s
ignature:
Name
Address
Telephone num
ber
Name:
Relationship:
Home
:
( )
-
Cell
:
(
) -
Alternative
:
(
) -
Name:
Relationship:
Home
:
( )
-
Cell
:
(
) -
Alternative
:
(
) -
Name:
Relationship:
Home
:
( )
-
Cell
:
(
) -
Alternative
:
(
) -
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