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Registration Form
450 Blue Mountain St. Coquitlam BC V3K 4K5
info@littletreasuresdaycare.ca 604-931-5593
1
For office use only:
Date of Enrollment: _______________
Date of Resignation: _______________
Personal Information
Full Name of Child: ____________________________ Gender: __________________
Name Child Responds To:_______________________ Date of Birth: _______________
Address: ________________________________________________________________
________________________________________________________________
Phone Number: ___________________________
Mother’s Name: _______________________ Place of Employment: _______________
Home Phone: __________________________ Work Number: _____________________
Cell Number: ___________________
Address (if different from child’s): ___________________________________________
Father’s Name: _______________________ Place of Employment: ________________
Home Phone: _________________________ Work Number: _____________________
Cell Number: _______________________
Address (if different from child’s): ___________________________________________
Persons Authorized to Pick up Child (other than parents listed above)
1) Name: __________________________ Relationship: _________________________